Counseling Intake Form

Counseling Intake Form
Completing our intake process can take 10-15 minutes, and once you begin, you cannot return to this page. Please have the following items ready before you start:
- A valid photo ID
- Your insurance card
- Any legal paperwork establishing custody or guardianship
After clicking Submit on the screening form, you will be redirected to our e-signing platform, SignNow, to review and sign our intake paperwork to become an established client.

If you would like assistance while completing the paperwork, our services coordinator is available to guide you over the phone. Call us at 910-493-3555 for support, or schedule a brief visit with our receptionist for a tour of the clinic.
Are you 18 years or older and legally able to make your own decisions, or are you a parent/legal guardian completing this form for a minor or someone under guardianship?*

Yes, I am 18 or older and can legally make my own decisions.No, I am completing this form as a parent/legal guardian for a minor or someone under guardianship.
Before we can schedule your appointment, you'll need to complete our intake paperwork. Once you finish this screening form, we'll send the documents to you. How would you prefer to receive your intake forms?*

Text Message (SMS)Email
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Primary Language*

EnglishSpanishOther

Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Email (If different from client's email)
example@example.com
Do you have legal paperwork that establishes custody or guardianship of the child?(If so, you will be asked to upload it.)*

No — I am the legal caregiver, and no custody paperwork exists.Yes — I have legal custody/guardianship and will upload documentation

Please upload the legal paperwork establishing custody or guardianship (e.g., custody order, DSS paperwork, guardianship documents). *

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Patient Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Referral Source
ADA Accommodations

Will you be filing insurance?*

Yes, I will be using an insurance to pay for services.No, I will be paying out of pocket for services.
Do you have a secondary insurance?*

Yes, I am covered by two insurances.No, I am covered by one insurance or I will be self-pay.

Upload the front of the insurance card covering the client.*

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Upload the back of the insurance card covering the client.*

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Upload the front of the secondary insurance card covering the client.*

Cancelof
Upload the back of the secondary insurance card covering the client.*

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Upload the front of your Driver’s License or State ID.*

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Upload the back of your Driver’s License or State ID.*

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Mental Health History
Why you are seeking treatment?*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

YesNo
Are you willing to be seen via Telehealth?*

YesNoMaybe/Unsure
Are there any open DSS investigations/custody issues we need to be aware of?*

YesNo
Questions and/or Requested Provider

Symptom Screener

Instructions to parent/guardian:
Below are questions about your child’s behaviors and feelings over the past month. Please choose the answer the aligns with how often each statement has been true.
My child has seemed sad, down, or hopeless.*
My child has lost interest in activities they usually enjoy.*
My child appears nervous, tense, or on edge.*
My child worries excessively or has a hard time controlling worries.*
My child has repeated thoughts that seem difficult for them to stop.*
My child feels driven to repeat certain behaviors or rituals.*
My child has nightmares, upsetting memories, or sudden reminders of past events.*
My child avoids people, places, or things that remind them of something upsetting.*
My child talks about hearing or seeing things others do not.*
My child believes others are out to harm them or control their thoughts.*
My child has had periods of being unusually energetic, excitable, or irritable.*
My child has needed little sleep or acted with racing thoughts.*
My child often argues with most adults or refuses to follow rules.*
My child has lied, stolen, or hurt others without showing guilt.*
My child has trouble focusing or finishing tasks.*
My child often loses or forgets important things.*
My child is unusually restless or has trouble sitting still.*
My child often acts before thinking or interrupts others.*
My child has used alcohol, vaping, or drugs.*
My child’s use of alcohol, vaping, or drugs has caused problems at home, school, or with friends.*
Function / Impact Section

How much have your child’s symptoms affected these areas of life in the past month?
School performance*
Relationships with family*
Relationships with friends/peers*
Daily responsibilities (chores, hygiene, following routines)*
Overall happiness and quality of life*

Symptom Screener

Instructions:
Below are questions about how you’ve been feeling or acting recently. Please circle how often each statement has been true for you over the past month.
I have felt sad, down, or hopeless.*
I have lost interest or pleasure in things I usually enjoy.*
I have felt nervous, anxious, or on edge.*
I have worried excessively or found it hard to control my worry.*
I have repeated thoughts or images that are hard to get rid of.*
I feel driven to repeat certain behaviors or rituals to reduce anxiety.*
I have unwanted memories, nightmares, or flashbacks about past events.*
I avoid people, places, or things that remind me of something upsetting.*
I have heard or seen things that others could not.*
I have felt that others were watching me, plotting against me, or controlling me.*
I have had periods where I felt unusually high, energetic, or irritable.*
During these times, I needed little sleep or felt my thoughts were racing.*
Before I turned 18, I often argued with adults or refused to follow rules.*
Before I turned 18, I lied, stole, or hurt others without feeling guilty.*
I have difficulty sustaining attention or completing tasks.*
I often lose or forget important things.*
I feel restless or have trouble sitting still.*
I often act before thinking or interrupt others.*
I use alcohol or drugs more than I mean to.*
I have tried to cut down on alcohol or drugs but couldn’t.*
My use of alcohol or drugs has interfered with my work, school, or relationships.*
Function / Impact Section

How much have your symptoms affected these areas of your life in the past month?
Work or school performance*
Relationships with family or friends*
Daily responsibilities (e.g., household tasks, self-care)*
Enjoyment of life / overall well-being*

You are almost there!
After clicking Submit, you will be redirected to our e-signing platform, SignNow, where you can review and sign our clinic policies. This ensures that you are fully informed about important clinic information before getting started.

If you would like assistance while completing the paperwork, our services coordinator is available to guide you over the phone. Please call us at 910-493-3555 if you’d like support, or schedule a brief visit with our receptionist for a tour of the clinic.

Important: Once you click Submit, you will not be able to return to this page. Don’t hesitate to reach out if you need help completing the forms.
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Counseling Intake Form

Mental Health History

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