Steeple Counseling Website Intake Form

Steeple Counseling Intake Form

Thank you so much for reaching out to Steeple! We are looking forward to connecting with you. Please note that this form is not to be used for emergencies, it is to be used for scheduling an appointment. If you are experiencing an emergency, please call 911 or go to the nearest emergency room.
Client Name*
First Name, Middle Name, Last Name
Please tell us a little about why you're seeking counseling.*
Relation to client*
Are you pursuing Individual, Family, or Couples Counseling?

Couples CounselingIndividualFamily
Please list your spouse's/significant other's name

First NameLast Name
Please list your spouse's/significant other's email address
example@example.com
Please list your spouse's/significant other's phone number
Name of individual filling out this form, if not the client*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Your Date of Birth*

MonthDayYear
Date
Client's Address (what you have on file with your insurance provider)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Address (what you have on file with your insurance provider)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your email address*
example@example.com
Parent/legal guardian's email address*
example@example.com
Best phone number to be reached at*
What type of phone is the number listed above?

Home PhoneCell Phone
When verifying insurance benefits and discussing scheduling, text is often the most effective form of communication. Are we able to text the number listed above?

YesNo
Please list the best way for us to contact you
Referral Information
How did you hear about Steeple?*
Are you currently connected to a church?*

YesNo
Which church?
Can we let your pastor or ministry leader know you've started your counseling journey?
Please sign here to confirm that you agree to us sharing with the individual listed above that you have begun counseling here at Steeple

Clear
Insurance and Billing Information
Do you plan on paying via insurance or self pay?*

InsuranceSelf Pay
Insurance Provider *
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber's Phone Number*
Subscriber's relationship to client*
Policy Number*
Group Number*
Please upload a picture of the Front of Your Insurance Card

Cancelof
Please upload a picture of the Back of Your Insurance Card

Cancelof
Please upload a picture of the Front of your State ID or Driver's License

Cancelof
Scheduling Information
Would you prefer a male or female counselor?*
Is there a specific counselor(s) you are interested in?
Are you interested in in-person or telehealth (video) sessions?*
What Does Your Availability Typically Look Like?*

Weekday MorningsWeekday AfternoonsWeekday EveningsOther
Communication & Privacy Policy Agreement
*Your signature below indicates that the information you have provided above is truthful as best to your knowledge.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Steeple Counseling Intake Form

Referral Information

Insurance and Billing Information

Scheduling Information