IHI Counseling Intake Form

Counseling New Client Intake Form

Please fill in the form below
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Number:*

Area CodePhone Number
E-mail*
Necessary to contact you, for invoicing, and for appointment notifications.
Please indicate if emailed invoices works for you. We generally ONLY send invoices through email. If for some reason you cannot receive and pay invoices by email/online please indicate below:

Yes, please send invoices by email only, I can receive them and pay them online or call and pay over the phone.No, I absolutely cannot receive invoices by email or pay online and must receive all invoices via USPS.
Emergency Contact Info
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
What is your gender identity? (Check ALL that apply)*

FemaleMaleCisgenderTransgenderTransgender Female/Transwoman/MTFTransgender Male/Transman/FTMGender QueerNonbinaryDecline to answerIntersexGender non-conformingOther
What is your sexual orientation: (check all that apply)

Hetrosexual (Straight)BisexualGayLesbianPansexualQueerQuestioningAsexualAromanticDemisexualOther
Pronouns you prefer*

She/Her/HersHe/Him/HisThey/Them/TheirsOther
Race*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latino, or SpanishNative Hawaiian and Pacific IslanderWhiteOther RaceDecline to answer
American Indian or Alaska Native Ethnicity

Navajo NationBlackfeet TribeMayanAztecNative Village of Barrow Inupiat Traditional GovernmentNome Eskimo CommunityWhite Earth NationOther
Asian Ethnicity

ChineseFilipinoAsian IndianVietnameseKoreanJapanesePakistaniCambodianHmongThaiBengaliMienOther
Black or African American Ethnicity

African AmericanJamaicanHaitianNigerianEthiopianSomaliGhanaianSouth AfricanBarbadianKenyanLiberianBahamianOther
Hispanic, Latino, or Spanish Ethnicity

Mexican or Mexican AmericanSalvadorianPuerto RicanDominicanCubanColombianOther
Native Hawaiian and Pacific Islander Ethnicity

Native HawaiianSamoanChamorroTonganFijianMarshallesePalauanTahitianChuukesePohnpeianSaipaneseYapeseOther
White Ethnicity

GermanIrishEnglishItalianLebaneseEgyptianPolishFrenchIranianSlavicCajunChaldeanOther
Other Race, Ethnicity, or Origin
Please type answer in box above
Do you currently take any medications for mental health related concerns?*

YesNo

List any current health conditions:
Have you ever been hospitalized for mental health conditions?*

YesNo
Have you had any major surgeries?*

YesNo
If yes, please list below
Have you ever sought counseling before?*

YesNo
If yes, when and where?
In the past 12 months have you considered suicide?*

NoYes
If yes, could you name any triggers:
Have you ever intentionally harmed yourself or attempted suicide?*

NoYes
If yes, please describe the situation and triggers:
Have you had any legal issues in the past or currently?*

YesNo

What is/are your goal(s) for counseling?*
How will you know when this goal(s) is/are met?*
Anything else you’d like us the know?
Current Concerns: (check all that apply or that you want to focus on)*

I have no problem or concernAbuse -- physical/sexual/emotional/neglect/cruelty to animalsAdjusting to work or schoolAggression/ViolenceAlcohol useAnger, Hostility, Arguing, IrritabilityAnxiety, NervousnessAssertivenessAttention, Concentration, DistractibilityBipolar DisorderCareer Concerns, Goals, and ChoicesChildhood Issues (your own childhood)CodependenceConfusionComing OutCompulsionsCustody of ChildrenDecision Making/Indecision, Mixed Feelings, Putting Off DecisionsDelusions (false ideas)DependenceDepression, Low Mood, Sadness, CryingDivorce, SeparationDrug Use - prescription, over-the-counter, street substancesEating Problems - overeating, undereating, appetite, vomitingEmptinessFailureFatigue, Low EnergyFearsFriendshipsGrievingInterpersonal ConflictsImpulsivenessCouple’s ConflictMotivationObsessions or CompulsionsOppressionPanic or Anxiety AttacksParentingPerfectionismProcrastinationSelf-EsteemSleep problemsStressSuicidal ThoughtsOther
Clinic Policies for Inside Health Institute

PLEASE READ CAREFULLY!
By signing below you are acknowledging agreement with the above clinic policies.

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Fees

Office Visits: Fees for appointments are determined by the client through a "Pay-what-you-can" tiered rate option. Further reduced rates may be available on a case-by-case basis. Please arrive on time for your visits in order to allow for the full time available for your session. If you need help with directions or accessing online appointments, please contact us at info@insidehealthinstitute.org or call 425-256-2125.

Insurance: We are out-of-network with all insurance companies. All visits are client pay and are not billable through insurance. If you need a coded bill to submit to insurance for reimbursement, our team may be able to provide you with one.

E-Mails: It is preferable that clients and clinicians communicate through our secure portal, Charm, rather than communicating by text or email directly with your clinician. Messaging or email should not be used for sole case management. If you need help accessing Charm or communicating with your clinician, please email info@insidehealthinstitute.org or call 425-256-2125.

Copies/Administrative Fees: If you need copies of chart notes or anything else, we will ask for payment to cover any expense to the clinic. Fees will be variable depending on the extent of the request. This does not include the complimentary printing of a few pages of information that your clinician may want to share with you but, rather, applies, to requests to do printing or copying that is outside of the normal client/clinician visit.

Appointment cancellations: Any no-show appointments or appointments canceled without 24-hour notice will be billed your full visit fee. These fees will be the patient’s responsibility.

Payment: Payment is made in person or through an invoice that will be emailed to you after your visit. Inside Health Institute accepts checks, cash, and credit cards (Visa, Mastercard, and Discover). Invoices and receipts are available by request. If you are experiencing financial hardship and need help making payments or need help with adjusting your fee or account balance, please contact us at info@insidehealthinstitute.org or call 425-256-2125 for help.

Returned Check Fee: There is a $25 fee for each returned check.

All fees are subject to change and patients will be kept abreast of these changes. If you have any questions regarding these guidelines please feel free to ask.
Please indicate which provider you are a new client of:*

Eileen BowenErin MullinsRobert DiazSasha MelnikAngela WhitneySam KrishnaLeah BrownEmmalee BozekMark EngelbergGrace BicketTara NairMaggie ButlerMegan WilsonElizabeth WrightCasey PhelpsRebecca WendfeldtOther
The type of counseling you are seeking:*

Individual Counseling for MyselfIndividual Counseling for A Person Under My CareCouples CounselingFamily Counseling
Which type of counseling would you prefer?*

In-PersonTelehealthUnsure
Were you referred by Open Path Collective?

YesNo
How did you hear about us?

Open Path CollectiveProject Access NorthwestPersonal ReferralSocial MediaOther

	Name of Medication	Dose
Medication
Medication
Medication
Medication

	Current	Past
Custody case
DUI
Divorce
Domestic Violence
Jail time
Prison time

Counseling New Client Intake Form

Emergency Contact Info

Clinic Policies for Inside Health Institute

CLINICIAN DISCLOSURE STATEMENT

Notice of Privacy Practices

Acknowledgement Of Privacy Practices