• Life Transitions screening questions

  • Complete this 20-minute form with no payment information required. Submitting this form is for preliminary information only and does not confirm an appointment.

  • Do you have any secondary or additional insurance coverage?*

  • At this time, we are only able to bill primary insurance and unable to bypass primary insurance to bill secondary insurance (Medicaid is always secondary).

  • Today's date*
     / /
  • For primary insurance, what is your relationship to the insured?*
  • According to your primary insurance are you Male, Female, Other? (This is strictly for billing purposes)*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • For secondary insurance, what is your relationship to the insured?*
  • According to your secondary insurance are you Male, Female, Other? (This is strictly for billing purposes)*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Format: (000) 000-0000.
  • Can we leave you a message?*
  • Can we leave you a text?*
  • Client's preferred method of contact. Check all that apply.*
  • Client's date of birth*
     - -
  • Do you have a preference for a male or female clinician?*
  • Would you like telehealth or in person sessions?*
  • Format: (000) 000-0000.
  • Preferred method of contact for emergency. Check all that apply.
  • Which services are you seeking?*
  • Who will participate in the service?*
  • Are you seeking services for assessment, evaluation, or documentation for any of the following?*
  • Are you looking for any of the following specialized treatment services?*
  • Are you currently involved in a custody dispute or in need of visitation or reunification services?*
  • For minor clients (17 years & younger), is there a parenting plan in place?*
  • Are you currently involved in services with any other mental health providers?*
  • Have you discharged from crisis stabilization or psychiatric hospitalization in the last 12 months?*
  • Was your admission voluntary?*
  • Approximate date of discharge*
     - -
  • Have you used any substances, including alcohol, in the last 30 days?*
  • Have you participated in substance use treatment in the last 12 months?*
  • What type of substance use treatment did you participate in?*
  • Do you have any concerns about your safety or the safety of anyone in your household?*
  • In the past 90 days, have you experienced any thoughts of harming yourself?*
  • Have you actually had any thoughts of killing yourself in the last 90 days?*
  • Have you thought about how you might do this? For example: “I thought about taking an overdose, but I never worked out the details about when, where, and how I would do that, and I would never act on these thoughts.”*
  • Have you had any intention of acting on these thoughts of killing yourself, as opposed to having the thoughts but knowing that you definitely would not act on them? For example: “I had the thought of killing myself by taking an overdose and am not sure whether I would do it or not.”*
  • Have you started to work out, or actually worked out, the specific details of how to kill yourself, and did you actually intend to carry out the details of your plan? For example: “I am planning to take three bottles of my sleep medication this Saturday when no one is around to stop me.”*
  • In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life? For example: Took pills, tried to shoot yourself, cut yourself, tried to hang yourself, took out pills but did not swallow any, held a gun but changed your mind about hurting yourself or it was taken from you, went to a roof to jump but did not, collected pills, obtained a gun, gave away valuables, or wrote a will or suicide note.*

  • In order to provide you with the best services, please share the following details.

  • When was the last time you engaged in that activity?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • In the past 90 days, have you experienced any thoughts of harming someone else?*
  • Have any of the following occurred in your household in the last 90 days*

  • LIMITED SECRETS POLICY

  • When working with couples and families, the entirety of the group is considered to be the client. At the beginning of treatment, we will co-create goals for the group. It is of vital importance to build and maintain trust with everyone attending therapy in order to openly, honestly, and thoroughly ask the questions and explore the issues relevant to achieving your established treatment goals. 

    During the course of treatment, it may be periodically helpful to see individual members or smaller sections of the group (e.g. one partner in a couple; children without parents or vice versa; one parent with one child; etc.) with the intention of benefiting treatment for the group as a whole. 

    Should we have an individual or smaller group session and a secret is disclosed, every effort will be given to approach these circumstances as collaboratively as possible. Together, we will discuss the potential implications on treatment, considering the interests and needs of everyone involved. Ultimately, I reserve the right to determine if this information is or has the potential to be therapeutically significant, and therefore necessary to disclose to the entirety of the group. If that is the case, we will work together to co-create a plan to disclose the information in a safe and therapeutic manner, including support for the individual or smaller group to self-disclose, if appropriate. 

    If you feel it necessary to talk about matters that you absolutely want to be shared with no one, I recommend that you discuss these matters with a therapist you can see on an individual basis. 

    By signing this form, you are acknowledging that you have read this policy and understand its contents. This policy applies to all contact, including therapy sessions, as well as communication by phone, email, or any other means. 

  • Client's signature date - 1*
     / /
  • Client's signature date - 2*
     / /

  • If you are finished, please submit the response.

  • Should be Empty: