Today's Date
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Month
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Day
Year
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New Client: Pre-Screening Form
Preparer Name & Relation (to new client)
*
Self, Parent/Guardian, Significant Other, Sibling, Other
Client Name (First, Middle, Last)
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Date of Birth
*
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Month
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Day
Year
Date
Email address
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example@example.com
Mailing address
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Phone Number
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Insurance
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Aetna
BCBS
Carelon (Empire/Anthem)
CDPHP
Cigna
Fidelis
Highmark
MVP
Optum
United Health Care/Optum
Other
Session Preference
*
Telehealth
In-Person
Hybrid
No Preference
Session Availability
*
Morning
Day
Evening
Other
Therapist Preference
*
Dacia McBean
Joseph Twumasi-Ankrah (Dr. A)
Nick Mojica
Susan Odom
Tanya Henderson (Dr. T)
Veneilya Harden (Dr. Vee)
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)
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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
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of
Upload Photo of Primary Insurance Card (back)
*
Browse Files
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of
Upload Photo of Secondary Insurance Card (Medicaid)
Browse Files
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of
Signature
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