Counseling Program Intake

Request for Therapy Services

Please fill out all fields to the best of your knowledge. This form is best filled out on a computer or tablet. If any question is unknown, please enter N/A or unknown.
Date*

MonthDayYear
Date
Referring person:
Referring Person -Name (first and last) *
Referring Person -Relationship to Person needing therapy
(eg. parent, advocate, SFA, self)
Referring person's email Address*
Referring Person -Phone Number*

Area CodePhone Number
Select one*

Ok to leave voicemailOk to textOk to leave voicemail or textDo not leave voicemail or text
Client information:
Client Legal Name (first and last)*
Client Preferred Name*
Date of Birth*

MonthDayYear
Date
Client Email*
Client Phone Number*
Select one*

Ok to leave voicemailOk to textOk to leave voicemail or textDo not leave voicemail or text
School attending*
Grade*
What is the reason for this referral?:*
Does Client have Health Insurance? (Insurance is not required to receive services)

YesNoUnsure
If Client has insurance, list the Insurance Company name here
(eg. BlueCross BlueShield, Iowa Total Care, Aetna, etc.)
Parent/Guardian Information

If under 18, guardian MUST be notified prior to making the referral
Guardian 1 Name *
First and Last
Guardian 1 Email*
Guardian 1 Phone*
Guardian 1- Select one*

Ok to leave voicemailOk to textOk to leave voicemail or textDo not leave voicemail or text
Guardian 2 Name
Guardian 2 Email
Guardian 2 Phone
Guardian 2 - Select one

Ok to leave voicemailOk to textOk to leave voicemail or textDo not leave voicemail or text
Should be Empty:

Request for Therapy Services

Referring person:

Client information:

Parent/Guardian Information