Request Talk Therapy Services

Request Talk Therapy Services

Client Demographic Information

Parent/Guardian Demographic Information

Insurance Information

Psychological Services Information

Substance Use History

Family History Information

Medical History

Educational History

Therapy History

Current Behavioral Concerns

Consent

Request Talk Therapy Services

Thank you for reaching out! This form helps us understand you, your child, or your family and the support you’re hoping for. Your answers guide our intake and waitlist process and are confidential. A team member will contact you within 48 business hours with more information. Please review the full form before starting so you have any information or files you may need. The form must be completed and submitted in one sitting.
Client Demographic Information

Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Name of Individual Completing the Form

First NameLast Name
Who are you filling the form out for?

Other
Contact Email Address
We highly utilize email to communicate during the treatment process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment progress.
Adult/Child's Legal Name

First NameLast Name
Adult/Child's Preferred Name

First NameLast Name
Adult/Child's Date of Birth

MonthDayYear
Date
If filling out for a minor child, is the child adopted or in foster care?
Adult/Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number

Area CodePhone Number
Adult/Child's Birth Sex
Adult/Child's Gender
Adult/Child's Pronouns
Adult/Child's Race/Ethnicity
Adult/Child's Religion/Spirituality
Parent/Guardian Demographic Information

If the individual seeking therapy is a minor or has a legal guardian, please fill out this section. Please provide as much information as possible to help guide the initial steps of the therapy process. Thank you!
Legal Guardian #1 Legal Name

First NameLast Name
Relationship to Client
Legal Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian #1 Phone Number

Area CodePhone Number
Legal Guardian #1 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #1 Marital Status
Legal Guardian #1 Education Level
Do you or your child/adult have another legal guardian responsible for making their medical decisions? If so, please provide that information below. If they do not have other legal guardians, you may indicate so in the drop-down and proceed on to the next section.
Legal Guardian #2 Legal Name

First NameLast Name
Relationship to Client
Legal Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Guardian #2 Phone Number

Area CodePhone Number
Legal Guardian #2 Email Address
We highly utilize email to communicate with caregivers throughout the therapy process. Please provide us with the best email address to contact you at regarding paperwork, scheduling, and treatment.
Legal Guardian #2 Marital Status
Legal Guardian #2 Education Level
Insurance Information

Please provide all relevant insurance information for your child/adult below. Failure to submit the accurate, current cards may result in a delay in services and/or the client being responsible the cost of services.
Name of Insurance Provider
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)

First NameLast Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth

MonthDayYear
Date
Member Identification Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please upload a copy of the front of your child/adult's current insurance card.

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Please note, you will not be added to the waitlist without a clear copy of the insurance card. Cancelof
Please upload a copy of the back of your child/adult's current insurance card.

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Please note, you will not be added to the waitlist without a clear copy of the insurance card. Cancelof
Do you or your child/adult have secondary coverage? (i.e. Medicaid and Private Insurance.) If so, please provide that information below. If you do not have secondary coverage, you may indicate so in the drop-down and proceed on to the next section. Please note, failure to report secondary insurance information may result in being responsible for the cost of services.
Name of Policy Holder (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)

First NameLast Name
Policy Holder Social Security Number (Note: This will be the child/adult for Medicaid, but may be the parent/guardian for BCBS)
Enter the Social Security Number W/Dashes here.
Policy Holder Date of Birth

MonthDayYear
Date
Member Identification Number
Found on the front of the insurance card.
Member Group ID Number
Found on the front of the insurance card.
Please upload a copy of the front of your child/adult's current secondary insurance card.

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Please note, you will not be added to the waitlist without a clear copy of the insurance card. Cancelof
Please upload a copy of the back of your child/adult's current secondary insurance card.

Browse Files
Please note, you will not be added to the waitlist without a clear copy of the insurance card. Cancelof
Psychological Services Information

Our office is open Monday–Friday, 8:30 am–4:30 pm, and talk therapy sessions are scheduled during these hours. We do not provide crisis or emergency services. If you or someone you care about is in immediate danger or experiencing a mental health crisis, please call 988 (Suicide & Crisis Lifeline) or 911 for local emergency services. Your safety and well-being matter. Please reach out for help right away if you are in distress.
Where are you requesting services?
Have you/has your child ever received a mental health diagnosis? If yes, please select it here.
Please upload any previous psychological assessments or diagnostic reports here.

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Please check any experiences you’ve/your child has had recently or at any point in the past. There are no right or wrong answers.

Other
Has the adult/child ever had feelings or thoughts about harming themselves?
Has the adult/child ever attempted to harm themselves?
Is the adult/child currently thinking about harming themselves?
On a scale of 0 to 10, (ten being strongest) how strong are thoughts of dying or attempting suicide currently:
Has the adult/child ever been treated at an inpatient psychiatric facility?
If yes, please describe when, by whom, and the nature of treatment received.
Substance Use History

Some people reach out for counseling with questions or concerns related to alcohol or other substances. You’re welcome to share as much or as little as you’d like here.
Is substance use something you'd like support with right now?
If yes or maybe, which best fits? (check any)
If yes or maybe, how would you describe the level of concern (if any)?

Check if the child/adult has ever used or is currently using the following:

Rows	Past Use	Current Use	Never Used
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy

How many caffeinated beverages does the child/adult consume in a day?
Has the child/adult ever smoked cigarettes?
If they have quit smoking, how long ago did they quit?
How many packs per day?
How many years did they smoke for?
Family History Information

Family relationships and support systems can shape what people are going through. Please share anything here that feels relevant.
Who currently lives in the home?

Other
What languages are spoken in the home?
Is family or caregiver support something you're hoping to include in counseling?
Are there family relationships that are important to know about right now?
Who currently lives at home with the child or adult? (Include sibling names and ages, please.)
Is there a history of any of the following in the child/adult's family?
Was the child/adult adopted?
Has the child/adult experienced neglect, abuse, or exploitation by a family member?
Medical History

Some health factors can affect mood, energy, or counseling logistics. Please share anything here that feels important.
Do you exercise regularly?
Are there any health considerations you’d like me to be aware of?
Are you currently taking medications that affect mood/emotions, sleep, or focus?
Do you anticipate needing coordination with your prescriber?
Do you need any accommodations for counseling sessions? (check any that apply)
Have you had any significant illnesses, hospitalizations, or surgeries? If so, please explain.
Is there anything else health-related you’d like your counselor to be mindful of?
How much time do you spend being active each day?
Name of Primary Care Physician

First NameLast Name
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician Phone Number

Area CodePhone Number
Date of Last Physical Exam/Wellness Check

MonthDayYear
Date
Copy of Current Physical

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Note: Failure to provide a clear, legible physical form dated within the last 365 days will result in a delay in being placed on the waitlist for services. Please call 620-330-9036 to have the form emailed to you prior to talking with your doctor. Cancelof
Does the child or adult have any allergies? If so, what are they?

Please list all of the child or adult's current medications, including name, dosage, time(s) of day given, purpose of the medication, and who prescribed the medication. Write N/A in the top row if they are not on medications.

If you ran out of room above, please continue to list the child or adult's medication information below.
Does the child or adult have any history of infectious diseases or other diagnoses we should know about?
Does the child or adult have a history of seizures? Please include the type and current treatment if so.
Educational History

Learning and school experiences can shape stress, identity, and daily functioning. Please share anything here that feels relevant.
What best describes the current situation?
If in school, what setting best fits?
Are there any learning or school-related concerns you're hoping to get support with? (Check any)

Other
Are any school supports currently in place?
Does the child or adult attend school?
Name of School
What grade is the child or adult in?
Name of Teacher

First NameLast Name
Did/Does the child or adult have an IEP/504 plan?
Anything else you would like us to know about the child or adult's educational or school history?
Please upload the child or adult's most recent/current IEP/504 plan.

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Therapy History

Many people receive different kinds of support at different times. Please share anything that feels helpful for us to know.
Has the client received any supports or services in the past or currently?
If yes, which types of support? (Check any that apply)
Are of these supports currently ongoing?
Would you like coordination with other providers (now or in the future)?
Is there anything else about past or current supports/services that you'd like me to know right now?
If yes, please provide the name of the provider and the service the child or adult received.
Has the child or adult received ABA therapy services in the past, including parent coaching services?
If yes, please provide the name of the provider and the service the child or adult received.
Does the child or adult receive speech, occupational therapy, physical therapy? Have they received them in the past? (If no, please skip the provider section below.)
Which therapy has the child or adult received?
Name of Provider (Speech)

First NameLast Name
Provider Address (Speech)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Speech)

Area CodePhone Number
Name of Provider (Occupational Therapy)

First NameLast Name
Provider Address (Occupational Therapy)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Occupational Therapy)

Area CodePhone Number
Name of Provider (Physical Therapy)

First NameLast Name
Provider Address (Physical Therapy)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Physical Therapy)

Area CodePhone Number
Is there anything else you'd like our team to know about the child or adult's therapy history?
Current Behavioral Concerns

Some behaviors can make daily life, learning, or emotional safety harder. Sharing here helps us understand support needs. You can share as much or as little as you’d like.
Are there any current behaviors or safety concerns you’d like support with?
Please select if the child or adult currently engages in the behavior or has engaged in the behavior in the last six months:
For children or those with autism-- If yes, which best fit right now?
For teens and adults-- If yes, which best fit right now?
Is anyone currently in immediate danger? If yes, please contact emergency services or a crisis line immediately. •Crawford County 24/7 Crisis Save Line: 620-232-SAVE (7283) •Four County Mental Health Center – 24/7 Crisis Line: 1-800-499-1748. •Spring River Mental Health & Wellness – After Hours Crisis Line: 1-866-634-2301
If applicable, what's something you'd like me to know that is not listed on this form?
Are there any other behavioral concerns you'd like our team to know about?
How did you hear about our services?
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Consent

The information I have provided for myself, my child, or the adult is accurate and true to the best of my ability and I am legally authorized to disclose this information.
Self/Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Medication Name

Time of Day Given

Purpose of Medication

Who prescribed the medication?

When was the med first prescribed?

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5