Today's Date
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Month
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Day
Year
Date
New Client: Pre-Screening Form
Preparer Name & Relation (to new client)
*
Self, Parent/Guardian, Significant Other, Sibling, Other
Client Name (First, Middle, Last)
*
Date of Birth
*
/
Month
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Day
Year
Date
Email address
*
example@example.com
Mailing address
*
Phone Number
*
Insurance
*
CDPHP
Fidelis
Aetna
MVP
United Health Care/Optum
Optum
Cigna
Other
Session Preference
*
Telehealth
In-Person
Hybrid
No Preference
Session Availability
*
Morning
Day
Evening
Other
Therapist Preference
*
Male
Female
No Preference
How did you find out about 1st Step Counseling (formerly Our Village Services)?
Psychology Today, Family/Friend, Google Search, Client
What are the presenting concerns you hope to address in counseling (explanation of the problem(s), duration, and cause(s)?
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Risk (potential or actual risk(s); select and explain)
*
Self-harm
Suicide
Homicide
Violence
Trauma
Substance abuse
Psychotic break
Runaway
Gambling
Other
List three goals you want to accomplish:
When are you available to schedule your initial consultation?
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Month
-
Day
Year
Date
Insurance Member ID/Policy Number
*
Upload Photo of Primary Insurance Card (front)
*
Browse Files
Cancel
of
Upload Photo of Primary Insurance Card (back)
*
Browse Files
Cancel
of
Upload Photo of Secondary Insurance Card (Medicaid)
Browse Files
Cancel
of
Signature
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