STILLWATER WELLNESS

Welcome to Stillwater Wellness!

I am so glad you've chosen to begin your wellness journey with me. My goal is to provide a safe, supportive, and confidential space where you can explore, heal, and grow.

This packet will help me get to know you, your needs, and your preferences, so I can provide the best possible care. Please take your time filling it out - there are no "right" or "wrong" answers.

Please complete all sections of this packet as fully as you can. If something doesn't apply to you, simply leave it blank or mark "N/A." All information you provide is strictly confidential and protected by the law. If you have any questions while completing this packet, email me at Jen@stillwaterwellness.life.

I am looking forward to walking alongside you in this next chapter of your life.
New Client Intake
Date

MonthDayYear
Date
Full Legal Name
Preferred Name
Pronouns:
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contact Name & Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Insurance Provider
Policy Number
Group Number
Insured's Name & DOB (if different)
By signing below, I understand that I am responsible for payment if services are not covered by my insurance. If my insurance coverage changes, it is my responsibility to promptly inform my provider.

Powered by Jotform SignClear
Reason for seeking counseling:
Current symptoms/issues:
How long have these been present?
Previous mental health treatment?

YesNo
If 'yes,' please describe:
Please list any current medical conditions:
Medications:
Past history of psychiatric hospitalizations?

YesNo
If 'yes,' please describe:
Have you ever attempted suicide or had past thoughts of hurting yourself?

YesNo
Do you currently have thoughts of hurting yourself?

YesNo
What is your occupation?
Are you currently enrolled in school?

Middle schoolHigh schoolCollege/TradeNone
What is your current living situation?

Permanent housingStaying with othersHomelessFacilityOther
Do you feel safe at home?
Who do you consider as part of your support system?
Who currently lives in your home? (relationship & age)

Availability: what dates/timeframes would work best for you?

	Mon	Tue	Wed	Thur	Fri
Mornings
Afternoons
Evenings

Informed Consent for Treatment

I understand that counseling and therapy are collaborative processes that may include exploring personal history, current concerns, and future goals. I understand that there may be moments of discomfort as part of the healing process, and I have the right to pause or stop at any time.

Confidentiality

I understand that my therapist will keep my information private, except in cases where disclosure is required by law - such as suspected abuse, danger to self or others, or a valid court order.

Telehealth Consent

I consent to participate in therapy sessions via secure video conferencing. I understand the potential risks and benefits of telehealth and agree to keep my environment private and free from interruptions during sessions.

Cancellation Policy

I understand that if I need to cancel or reschedule an appointment, I will give at least 24 hours notice. Missed appointments without notice may result in a $50 fee.

Digital Signature

I agree that my electronic signature on this document has the same legal effect as a handwritten signature.
Client Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Full Printed Name
Should be Empty:

New Client Intake