New Client Request Form

New Client Request Form
Today's Date*

MonthDayYear
Date
Client Information:
Full Legal Name*

First NameMiddle NameLast Name
Name that you go by
Biological Sex*
Gender identity
Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
SSN
Primary Phone Number*
Consent to Texts*
Consent to Voicemail*
Email*
example@example.com
Consent to Email*
*Please note that consenting to email provides you access to your patient portal which allows you to complete your initial paperwork electronically.*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
How did you hear about Still Waters*
If client is a minor, or is an adult with a POA or legal guardian, please complete the section below:
Responsible Party

First NameLast Name
Responsible Party Phone Number
Relation to client
(Parent, Legal Guardian, POA)
REQUIRED: Please take a clear picture of the Front AND Back of Driver's License or Picture ID of Client (and/or Responsible Party)*

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Payment related Information:
Coverage for services*
We encourage you to contact your insurance company to verify your mental health benefits and to be sure that your provider is in network with your current insurance provider.

PLEASE COMPLETE ALL FIELDS IF YOU INTEND FOR YOUR INSURANCE TO BE BILLED FOR SERVICES
Primary Insurance Company Name *
If none, please enter "None"
*If your card states that your mental health benefits are provided by another company please enter both names here. For example: Cigna is on the front of your card, but on the back it says mental health: Optum.

*If you have Medicaid or Medicare, please specify which type (MCO).
Insurance Member ID *
If no insurance, enter N/A
Insurance Group Number
Insurance Phone Number
Policy Holder Name

First NameLast Name
Relationship to the client
Policy Holder Phone Number
Policy Holder DOB

MonthDayYear
Date
Policy Holder SSN
Policy Holder Address (if different from patient):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Employer
REQUIRED: Please take a clear picture of the Front AND Back of your Primary Insurance Card:

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Secondary Insurance Company Name
Required if you have a Secondary Insurance
Secondary Insurance Phone Number
Secondary Insurance Member ID
Secondary Insurance Group Number
Secondary Policy Holder Name

First NameLast Name
Relationship to the client
Secondary Policy Holder Phone Number
Secondary Policy Holder DOB

MonthDayYear
Date
Secondary Policy Holder SSN
Secondary Policy Holder Address (if different from patient):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Policy Holder Employer
REQUIRED: Please take a clear picture of the Front AND Back of your Secondary Insurance Card:

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Presenting Concerns:
Please describe the concerns that you are seeking counseling for: *
History of and/or current Mental Health Diagnosis given by Mental Health Professional (Psychiatrist, Psychologist, Licensed Counselor) :*

YesNo
If Yes, please specify:
Have you been given diagnosis of a Developmental Disability by qualified Healthcare Professional:*

YesNo
If Yes, please specify:
Is substance misuse one of the primary reasons that you are seeking counseling?*

YesNo
Are you currently using or misusing any chemical substances?*

YesNo
Are you currently seeking services due to legal issues:*

YesNo
If Yes, please specify:
Service you are interested in*
If seeking Couples Counseling:
Availability*
*Please note that most therapists require your initial intake session to be in-person*
Have you been seen at Still Waters before ?*

YesNo
If Yes, who did you see? What year?
History of Counseling Services
Do you have any Medical Conditions that our office should be informed and aware of?
Is there any additional information that you would like to share with us?
Type a question
Thank you for reaching out to us! We appreciate you taking the time to complete our new client pre-registration form. This information is helpful to us as we work to connect you with your Still Waters therapist.

One of our administrative assistants will be in contact with you soon.
Should be Empty:

New Client Request Form

Client Information:

Payment related Information:

Presenting Concerns: