New Client Pre-Screening Form
Mental Edge Counseling, LLC
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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General Information
Reason for wanting to schedule with us?
*
ADHD
Anxiety
PTSD
Depression
Family Therapy
Marriage/Relationship counseling
Substance / Alcohol abuse
Court Ordered
Learning Disabilities
Personality Disorder
Eating Disorder
Grief / Death Counseling
Domestic Violence
Child Abuse
Child Sexual Abuse
Medication Management Services
LGBTQ+
Learning Disabilities
Development Disabilities
Trauma
Behavioral Issues
Bariatric Clearance
Juvenile Sex Offender
Autism / Aspergers Disorder
Other
TMS (Transcranial Magnetic Stimulation)
Please explain
*
Have you been seen at a mental health office in the last 12 months?
*
Yes
No
If yes, where did you receive those services?
Are you currently on any Psychiatric Medications?
*
Yes
No
If yes, what medications and who prescribes these medications?
What is your insurance carrier?
*
Please Select
Blue Cross Blue Shield of DE
Highmark Health Options
Amerihealth Caritas of DE
Cigna
Medicare
Tricare
UnitedHealth Care
Aetna
Self-pay
Other
So we can ensure you are matched up with a provider that can take your insurance!
Are you interested in virtual services(telemedicine) only after the initial intake appointment?
*
Yes
No
Maybe
Please select days of week that would work best for your appointment
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any Day
Please select time(s) of day(s) what would work best for your appointment
*
8AM
11AM
2PM
5PM
9AM
12PM
3PM
6PM
10AM
1PM
4PM
7PM
Any Time
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Additional Questions / Information
Is this related to a disability claim?
*
Yes
No
Is this related to a Worker's Comp claim?
*
Yes
No
Is this related to an Auto Accident?
*
Yes
No
Is this a custody case or is there a potential to be a custody case in the future? (if yes, please be prepared to fax/email any pertinent documents)
*
Yes
No
Are you currently on probation?
*
Yes
No
If yes, what is the reason?
If on probation, are services court ordered?
Yes
No
Were you professionally referred to our office?
*
Yes
No
If yes, who were you referred by?
How did you hear about us?
*
Please Select
Friend / Family
Google Search
Social Media
Web Search
Advertisement
Signage
Other
Any other information you would like to include?
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