New Client Set-Up

Client Information
Client's Full Name*

First NameLast Name
Preferred Name
Client's Date of Birth*

MonthDayYear
Client's Sex*
Client's Pronouns
Contact information MUST be for the CLIENT

If the client is 13 years or younger, one parent's email address and phone number can be used for the client
Client's Phone Number*
Client's Email Address*
Client's Address*

Street Address

Street Address Line 2

CityState

Zip Code

Availability & Preferences
Indicate type of service preference:*

Telehealth OnlyIn-Office OnlyHybrid / BothNo Preference

Please indicate specific hours that the client is available to meet for weekly sessions (e.g. 9AM, 11AM-2PM, 5:30PM-7:30PM)*

Note any potential scheduling conflicts:
Unless otherwise discussed with your Provider, sessions are typically held weekly.

To help ensure confidentiality and placement with an appropriate provider...
Has the client ever received mental health services with Therapy Resources?*

NoYes, with...
Does the client know or have a personal relationship with any of our providers (e.g. friends, family, past or current colleagues, etc.)?*

NoYes, with...
Is the client being discharged or has the client recently been discharged from a higher level of care?*

YesNo
Are there/will there be any other parties (e.g. attorney, DCP&P, etc.) involved in these services?*

YesNo

Additional User #3

NOTE: The purpose of an Additional User is to assist with the completion of the required forms and/or have access to client financial information (if applicable). If Release of Information Forms are required, they will be sent via the Patient Portal.
Additional User #3's Name

First NameLast Name
Additional User #3's Relationship to Client

Parent/Legal GuardianPartner / SpouseOther
Should Additional User #3 be included in the Intake and Scheduling process?

YesNo
(3a) Should Additional User #3 have access to the Patient Portal account?

YesNo
(3b) What patient portal access should Additional User #3 have?

Financial Access only (limited to billing forms)Full Access
Additional User #3's Date of Birth

MonthDayYear
Date
Additional User #3's Gender
Additional User #3's Phone Number
Please enter a valid phone number.
Additional User #3's Email
example@example.com
To include more additional users to these services, please email our Intake Department at intake@therapyresourcesmc.com. Please include the requesting Client's name and Date of Birth to ensure the information is going to the correct client.

Submitter Signature*

Clear
By signing this form, you are submitting a request for services with Therapy Resources of Morris County. For questions, please contact our Intake Department at intake@therapyresourcesmc.com
Should be Empty:

Client Information