Total Life Counseling & Wellness Intake

Counseling/Case Management Intake

Total Life Counseling & Wellness
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Referral Source
Guardian name if Patient is under 18

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
name of school if under 18
Brief reason for therapy
Email
example@example.com
Cell Phone
Date

MonthDayYear
Date
Insurance Information

Please Upload copy of card. (Front and back if you have commercial or private insurance. If you do not have a physical insurance card and you have Medicaid insurance, Please upload the client's Social Security Card.
File Upload*

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Authorization of Release of Information: JCPS

Authorization for provider to obtain or release relevant information pertaining to patient: Purpose of Release:This Release of Information authorizes Total Life Counseling and Wellness to exchange relevant educational and mental health information with all JCPS SCHOOLS to support the student’s academic, behavioral, and emotional needs. Shared information may include attendance, academic performance, behavior reports, Individualized Education Program (IEP) or 504 Plan details, and mental health progress updates.This exchange will help coordinate services, develop effective interventions, and ensure the student receives consistent support both in school and through counseling services.
Signature

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Confidentiality Statement:

The information shared in counseling at Total LIfe Counseling will be strictly confidential. Confidentiality is essential for fostering a safe and trusting therapeutic relationship. Confidentiality may be broken if there are any expressions or self harm, court orders, or medical emergencies.
*Your signature below indicates that you consent for treatment, release of information from JCPS if needed, and acknowledgment of confidentiality.
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Counseling/Case Management Intake

Insurance Information

Authorization of Release of Information: JCPS

Confidentiality Statement: