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Welcome to Joyful Life Institute, Inc.
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HIPAA
Compliance
1
Full Name
*
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First Name
Last Name
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2
Gender
*
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MALE
FEMALE
Other
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3
Date of Birth
*
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Indicate your Date of Birth (DOB)
-
Date
Month
Day
Year
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4
Personal Cell Phone Number
*
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Area Code
Phone Number
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5
Is it ok to leave a voicemail?
*
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YES
NO
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6
Is it ok to send a secure text?
*
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YES
NO
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7
Personal Email
*
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example@example.com
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8
Is it ok to send you a secure email?
*
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YES
NO
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9
Will you be in TEXAS during your virtual sessions with your therapist?
*
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YES
NO
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10
Are ALL parties who will participate over the age of 18?
*
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YES
NO
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11
How did you hear about our services?
*
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12
What services are you seeking?
*
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Individual Therapy
Intensive Therapy
Premarital Therapy (Couple)
Premarital Therapy (Group) Coming Soon!
Premarital Therapy (Self-Study) Coming soon!
Marriage/Couple Therapy
Family Therapy
Group Therapy
Coaching
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13
How do you plan to pay for therapy?
*
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Insurance
EAP
Self-Pay
Responsible Third Party
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14
What is the name of your behavioral health insurance or EAP company (if applicable)?
*
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AETNA
Beacon
CURALINC
HUMANA
Optum
PHCS
United Behavioral Health
United Healthcare
Other
Self-Pay
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15
Does your insurance cover telemental health? (Check with your insurance company before continuing).
*
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YES
NO
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16
Does each teletherapy session participant have a computer that has a good WIFI, webcam, light source, headphone/earbuds, and mike?
*
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YES
NO
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17
What is your level of experience with computers?
*
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Basic
Intermediate
Advance
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18
Do you have a safe, quiet place where you will not be disturbed while in the virtual therapy session?
*
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YES
NO
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19
What is the CURRENT ISSUE that caused you to seek counseling?
*
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20
What is the CURRENT EVENT that caused you to seek counseling?
*
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21
Have you EVER experienced any of the following in the PAST? (CHECK ALL THAT APPLY)
*
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Homicidal Thinking or Behavior
Suicidal Thinking or Behavior
Childhood Abuse or Neglect
Domestic Violence
Court/Legal Issues
Disability Leave
Mental Health Hospitalization
Substance abuse Hospitalization
NONE
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22
Are you CURRENTLY or on a ONGOING basis experiencing any of the following ? (CHECK ALL THAT APPLY )
*
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Homicidal Thinking or Behavior
Suicidal Thinking or Behavior
Childhood Abuse or Neglect
Domestic Violence
Court/Legal Issues
Disability Leave
Mental Health Hospitalization
Substance abuse Hospitalization
NONE
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23
If you checked DOMESTIC VIOLENCE whether past or current, did this violence occur between parties currently requesting services?
*
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YES
NO
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24
I am too sensitive to rejection.
*
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YES
NO
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25
It is hard for me to take instructions from people who have authority over me.
*
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YES
NO
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26
I argue with other people too much.
*
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YES
NO
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27
What DAYS and TIMES are you (both or all) available to meet for a telehealth session? (CHECK ALL THAT APPLY)
*
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Tuesday
Wednesday
Thursday
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:15 PM
2:15 PM
3:00 PM
4:00 PM
Not available at these times
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28
Signature
*
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Clear
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