New Client Assessment Form For Families
Please fill out this form to help us understand your needs and preferences for counseling services.
Primary Client
*
First Name
Last Name
Please check this box if you are the primary contact for scheduling the appointment.
Email Address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Member
*
First Name
Last Name
Please check this box if you are the primary contact for scheduling the appointment.
Please check if patient is a minor
Email Address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Member
First Name
Last Name
Please check this box if you are the primary contact for scheduling the appointment.
Please check if patient is a minor
Email Address
example@example.com
Phone number
example@example.com
Presenting Concern(s)
*
Court Involvement
*
Yes
No
If yes to court involvement, please explain.
Treatment Modality
*
In-person only
Telehealth only
Both in-person & Telehealth
Interested in Working with
Intern-Self-pay reduced rate
Provisionally Licensed Therapist
Payment Preference
Self Pay - Reduced Rate
Insurance
EAP Service Provider and Authorization Number:
Insurance Subscriber Name and DOB:
Insurance Card - Front and Back
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please check if you would like insurance benefits verified
Save
Submit Assessment Form
Should be Empty: