GGUS Intake Form

Intake Application
Girl, Get Up Society
Please provide the following information and answer the questions below. Please note: Information provided is protected as confidential information. Applicants MUST COMPLETE all required portions of this application to receive sponsored services.
Name*

First NameLast Name
Email address*
ex: myname@example.com
Street address*
City*
State*
Postcode*
Phone number*
Birth Date*

MonthDayYear
Age
Gender Identity*
Race*
Martial Status*
What is your level of education? Please specify highest grade/degree and type.*
What is your current occupation?*
Employment Status*
Primary Insurance Carrier*
Membership Intake
Please select your current Mental Health Challenge. (Check All That Apply)*

AnxietyDepressionPostpartum DepressionPost Traumatic Stress DisorderSuicide IdeationsOther

Please rate the severity of your current problems/symptoms.*

	Mild	Moderate	Severe
Anxiety
Depression
Postpartum Depression
Post Traumatic Stress Disorder
Suicide Ideations
Other

Are you able to financially contribute to your services? If so, how much?*
Which service would you like to receive?*
Are you interested in being seen by a Graduate/Masters level intern? *All interns are graduate level & have completed all in class requirements and only need counseling hours to graduate.*

YesNo
Which service do you prefer?*

In-personTelehealthBoth
Do you prefer faith-based services?*

YesNo
Please indicate your religious background.*
What brings you to therapy/life coaching at this time? Please indicate any recent life events and/or changes. Please be as specific as possible.*
What are your counseling/life coaching goals?*
Have you ever received Mental Health Services before? If so, please specify the reasons for services.*
Have you ever been diagnosed with a Mental Illness? Please specify*
Have you ever been hospitalized for a psychiatric issue?*

YesNo
Are you currently or have you ever taken any psychotropic medication and for what reasons? Please specify.*
Do you currently or have you ever drank alcohol or used illicit drugs?*

YesNo
Have you ever attempted suicide?*

YesNo
Are you currently having thoughts of suicide or self-harm?*

YesNo
Are you currently having thoughts of harming others?*

YesNo
Are you willing to work on individual goals with monitored progress?*

YesNo
Are you willing to commit to at least 3 months of therapy treatment?*

YesNo
Please indicate any additional information you would like for us to know.
Please indicate your shirt size.*
Notes about individual membership privileges: Members have the right to request removal from any services at any time. A 24hr notice is required for any sponsor-paid services.
MonthDayYear
Date
Signature*

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