Steeple Counseling New Client Form

Steeple Counseling New Client Form

Thank you again for reaching out to Steeple! It was a pleasure talking with you. We pray your time here at Steeple is fruitful and encouraging. 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
MaleFemale
Relation to client*
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*
Home PhoneCell Phone
YesNo
Please list the best way for us to contact you
Please Upload a Picture of Your Driver's License*

Cancelof
What is the primary reason for seeking counseling?
How did you hear about Steeple?*
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 here at Steeple so that they can begin supporting you in prayer and encouragement.
If you would like us to let the above person know that you’ve started counseling, please sign your name here
Insurance Information
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
MaleFemale
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*

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

Cancelof
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
Should be Empty:

Steeple Counseling New Client Form

Insurance Information