New Patient Enrollment Form

New Client Enrollment

Firm Foundations Counseling & Wellness
Client Name*

First NameLast Name
Contact Number:*
Client Date of Birth*

MonthDayYear
Date
E-mail
example@example.com
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Type*
Insurance ID#*
Insured Name*

First NameLast Name
Insured Date of Birth

MonthDayYear
Date
Do you/client have secondary insurance?

YesNo
If yes, input name and member ID number below.
Reason for visit

These questions will allow us to match you/client with the most appropriate clinician.
Indicate top reason(s) for seeking counseling services (no more than 3)*

DepressionAnxietyDepression related to motherhoodAnxiety related to motherhoodTraumatic ExperienceFinding my purpose in lifeCareer CounselingGender identityBehavioral issuesADHD TreatmentADHD TestingADHD for School AccommodationsEating DisorderPre- or postnatal mental health symptomsCouples / MaritalAutism 1 Mild (I have been tested and formally diagnosed)Autism 2 Moderate (I have been tested and formally diagnosed)Autism 3 Severe (I have been tested and formally diagnosed)Autism (I have not been formally tested)Substance use or abuseSerious mental illness (e.g. hearing voices)Developmental / learning delayDomestic violenceCheck here if you have experienced thoughts of suicide in the last 6 monthsCheck here if you have been hospitalized for mental health concerns in last 6 mos
If you are scheduling for someone else, have they ever been diagnosed with an intellectual disability or developmental delay?

YesNoUnsure
Have you/client ever been diagnosed with Borderline Personality Disorder

YesNo
Are you/client seeking our services to get prescribed medication for your condition?

YesNoUnsure
Legal Involvement

Answering 'yes' to these questions will not automatically rule you out for our services. Your answers help us ask you more questions at intake to determine which services are right for you.
Do you, your child, or any other caregivers have any ongoing legal cases?*

NO, I do not have any ongoing legal cases or legal involvement. I do not anticipate any ongoing legal cases or legal involvement.YES, I have an ongoing legal case, or I anticipate there may be one forthcoming.REFERRING PHYSICIAN - THIS INFORMATION IS UNKNOWN
Do you, your child, or any other caregivers have any ongoing custody or DSS cases?*

NO, I do not have any ongoing custody or DSS involvement. I do not anticipate any ongoing legal cases or legal involvement.YES, I have an ongoing custody or DSS case, or I anticipate there may be one forthcoming.REFERRING PHYSICIAN - THIS INFORMATION IS UNKNOWN
Is this treatment court ordered or mandated?

YesNoUnsure
Provider / Appointment Preferences

PLEASE NOTE THAT THE MORE FLEXIBLE YOU ARE ON PROVIDER AND APPOINTMENT TIME - THE SOONER YOU WILL BE ABLE TO GET IN FOR AN APPOINTMENT.
Provider Preferences - (check all that apply)

No preference - first availableMaleFemaleClinician of colorClinician familiar with LGBT+ communityClinician older in ageClinician younger in age
Appointment Time Preference (check no more than 2)

No preference - first availableMorningsAfter 12pmAfter 2pmAfter 3pmAfter 4pm
Setting Preference

In-officeVirtual / TelehealthI am open to either
Who completed this form

I completed this form for myselfI completed this form for my childI am a Physician and completed this form for patient referral
If Physician completed, indicate name here

First NameLast Name
If Physician completed, indicate fax number for referral response.
Please enter a valid phone number.
Should be Empty:

New Client Enrollment

Reason for visit

Legal Involvement

Provider / Appointment Preferences