Counseling Intake Form

Counseling Intake Form
Location Preference
Patient Name

First NameLast Name
What is your Gender identity?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Employment
If a minor, what school?
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
Emergency Contact Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship
Insurance Information

Please specify if your coverage is Medicaid, Private Insurance, or through an Employer.
Insurance Carrier/Company
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Group Number
Policy Number
Mental Health History
Is there a specific provider you are wanting to see?
Lauren Schenck (either location) Alexis Bloomfield (Fremont) Noah Sherman (Fremont) Alea Reifenrath-Sherman (Fremont) Ingrid Rodriguez (Columbus)
Why you are seeking treatment?
Areas of Concern
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Therapist Name

First NameLast Name
Please explain any legal, community support, child welfare, or probation involvement. (This does not exempt you from treatment!)
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature
Name

First NameLast Name
Should be Empty:

Emergency Contact Information