Release it Counseling Intake Form
You Must complete as the first step to schedule an appointment. Please make sure you slide this form up to see the entire form. As you cannot slide the page to slide up the form. This Form can be saved and continued for later.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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/
Month
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Day
Year
Date
Gender
*
Please Select
Male
Female
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Is your primary language English
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Yes
No
Please select the state that you will be located in for therapy
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
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Please describe your presenting problem?
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Briefly describe what you need from your therapist to help you be successful in therapy? Ex; honesty, support, promptness etc.
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Briefly describe what you want to achieve in therapy?
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Who would you say your present support system is? ex; friend, spouse, colleague etc.
Current Symptoms
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Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Hearing voices
Delusions
Other
Have you ever had feelings or thoughts that you didn't want to live?
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Yes
No
Do you currently feel that you don't want to live?
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Yes
No
Do you have or ever had a plan on how to commit suicide?
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How often do you have these thoughts?
When was the last time you had thoughts of dying? Please put "NA" if this question doesn't pertain to you.
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On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?
1
2
3
4
5
6
7
8
9
10
Weak
Strong
1 is Weak, 10 is Strong
Please answer the below questions
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Yes
No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?
Do you battle with extreme anger?
My emotions change very quickly, and I experience intense episodes of sadness, anger or irritability?
My level of anger is often inappropriate or difficult to control?
I engage in frantic efforts to avoid real or imagined abandonment by those close to me?
I have a significant and persistently unstable image of myself?
Have any of your closest relationships been troubled by a lot of arguments or repeated breakups?
Have you often been distrustful of other people
Have you often felt that you had no idea of who you are or that you have no identity
Current medical problems
Psychiatric History:
Have you been to therapy before?
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Yes
No
Please select if you've ever been diagnosed with any of the below
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Schizophrenia
Borderline Personality Disorder
Dissociative identity disorder- DID
None of the Above
Please list all previous mental health diagnoses. If none put "NA"
Have you ever been placed in Psychiatric Hospitalization
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Yes
No
If yes, Please describe when, by whom, and nature of treatment
Have you been seen by a psychiatrist/NP/PA/MD in the last year (365 days)?
Yes
No
You Must answer, If you answered yes to the previous question please list the providers and last date seen here
Past Psychiatric Medications
If you have ever taken any of the following medications?
*
Have you ever taken it?
Select this option if you've Never taken any psychotropic medications
Prozac (fluoxetine)
Zoloft (sertraline)
Luvox (fluvoxamine)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Effexor (venlafaxine)
Cymbalta (duloxetine)
Wellbutrin(bupropion)
Remeron (mirtazapine)
Serzone (nefazodone)
Anafranil (clomipramine)
Pamelor (nortrptyline)
Tofranil (imipramine)
Elavil (amitriptyline)
Tegretol (carbamazepine)
Lithium
Depakote (valproate)
Lamictal (lamotrigine)
Tegretol (carbamazepine)
Topamax (topiramate)
Seroquel (quetiapine)
Zyprexa (olanzepine)
Geodon (ziprasidone)
Abilify (aripiprazole)
Clozaril (clozapine)
Haldol (haloperidol)
Prolixin (fluphenazine)
Risperdal (risperidone)
Ambien (zolpidem)
Sonata (zaleplon)
Rozerem (ramelteon)
Restoril (temazepam)
Desyrel (trazodone)
Adderall (amphetamine)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Strattera (atomoxetine)
Xanax (alprazolam)
Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Tranxene (clorazepate)
Buspar (buspirone)
Has anyone in your family been diagnosed with or treated for:
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Bipolar disorder
Depression
Anxiety
Anger
Suicide
Schizophrenia
Post-traumatic stress
Alcoholabuse
Other
Check if you have ever tried or used any of the following substances?
*
Never used any illegal substances
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Other
Have you used any substances in the last 6 months?
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Yes
No
Are you presently using any Substances?
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Yes
No
Please list you present Substance of choice.
Are you seeking Substance abuse treatment?
Yes
No
Do you presently smoke cigarettes?
Yes
No
Personal History
Have you experienced any trauma; domestic violence, sexual abuse, child abuse?
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Yes
No
Are you currently:
Married
Partnered
Divorced
Single
Widowed
Are you seeking Couples counseling?
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Yes
No
Only answer if you are seeking couples counseling with INSURANCE PAYMENT. Please list the name of each of your individual therapist, and the last date that each of you attended your individual counseling.
Spouses Name
First Name
Last Name
Spouses Date of Birth
Spouses Email
example@example.com
Insurance Information
Please upload a copy of your Medical Insurance card front and back; you will have to upload two images. If you do not have a copy of your insurance you will have to input manually on next screen.
Browse Files
Cancel
of
Please Select your Insurance Provider
*
Please Select
Aetna Commerical or Medicaid
Anthem BCBS & Healthkeepers
Cigna
EAP- Anthem, Magellan, Optima
Megellan
Optima Commercial & Medicaid
Optum
TriCare Prime & Select
United Healthcare Commercial Only
Self Pay
Insurance ID
*
Policy Holders Name
First Name
Last Name
Policy Holders Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Policy Holder
Please Select
Spouse
Parent
Self
Do you have Medicaid?
Yes
No
Please select which services you are interested in, you may select more than one.
*
Individual Therapy
Couples Therapy
Medication Management
Life Coaching
Release it Counseling is a predominate hybrid office, that offers both virtual and face to face sessions. Although we offer face to face sessions, we cannot guarantee that you will be able to have face to face sessions. There may be times where you will have to have virtual sessions. Are you receptive to having tele-health (virtual) sessions?
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Please Select
Yes I am receptive, and I have no preference of virtual or face to face
Yes, I am receptive, but I prefer virtual sessions
Yes, I am receptive, but I prefer face to face
No I am not receptive to having virtual sessions
Are you receptive and agree to seek services with our specialty of Christian Counseling? As we are a Christian Counseling agency.
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Yes
No
Please select Your preferred therapist. Whitney is not accepting new clients.
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First Available/No Preference
Cameo Faulkner, MSW, LMSW- VIRTUAL ONLY
Elektra Smith, MSW
Dr. Church, PMHNP-BC- Medication Management Only
Yonette Cuneo, MSW, LMSW (Available Soon)
Please list times you are available for sessions; ex: "Tuesdays beginning at 3pm" Please read the proceeding therapists availability; This is the availability of Cameo; Monday-Friday-10a-5p (VIRTUALLY ONLY). Elektra; Tuesday-Friday 10a-4p (In Person Tuesday & Wednesday and Virtual Thrs & Frid).
Please select how you found our agency
Google
Psychology Today
Therapy For Black Girls
Referred by another therapist
Referred by colleague, friend or loved one
Referred by another agency
Other
Please include any questions comments or concerns you'd like to discuss prior to scheduling.
Client Signature
*
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