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
Relation to client*
Are you pursuing marriage or couples counseling?

YesNo
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
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*

Area CodePhone Number
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
How did you hear about Steeple?*
Are you currently connected to a church?*

YesNo
Which church?
Did you know: Many of our clients who are part of churches choose to let a pastor or ministry leader know that they are beginning counseling. If this describes you, and if you’d like to have a support person on file, please include their name, contact information and their role at the church. By including this information, we can further discuss what it could like to invite this person to participate in prayerful support and encouragement during your counseling journey. Specifically, we offer letting them know that you’re starting this journey so that they can begin supporting you in prayer and encouragement.
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 Information
Do you plan on paying via insurance or self pay?*

InsuranceSelf Pay
Insurance Provider *
Type N/A if not planning to pay via insurance
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber's relationship to client*
Policy Number*
Type N/A if not planning to pay via insurance
Group Number*
Type N/A if not planning to pay via insurance
Please Upload a Picture of the Front of Your Insurance Card

Browse Files

Cancelof
Please Upload a Picture of the Back of Your Insurance Card

Browse Files

Cancelof
Counseling Information
Briefly explain why you are seeking counseling*
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 Evenings
*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

Insurance Information

Counseling Information