Counseling Center Intake and Screening Form - Upstate
Please fill out the following information to help us understand your needs and provide the best support.
Full Name of Client
*
First Name
Middle Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Gender
Female
Male
Other
Client's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email Address
*
example@example.com
Client's Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Insurance Provider
Please Select
Absolute Total Care
Blue Cross Blue Shield
United Health Care
Molina
Cigna
Healthy Blue
Medicaid
Self Pay
Other
Name of Referent (if someone other than the client is completing the referral)
First Name
Last Name
Referent's Relationship to Client
Please Select
Parent/Guardian
Caregiver
Foster Parent
Case Manager
School
Provider
Family Member
GAL
Other
Contact for Scheduling (if other than client) ie. parent, guardian, case manager
First Name
Last Name
Phone Number for Scheduling (if other than client's phone number)
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address for Scheduling (if other than client's email)
example@example.com
Have you (or the client) previously received counseling or therapy?
*
Yes
No
Unsure
Are you (or the client) current recieving counseling or therapy?
*
Yes
No
Unsure
What are the presenting concerns related to the referral for services (check all that apply):
*
Anxiety
Depression
Trauma
Behavior Challenges
Substance Use
Relationship Concerns
Grief/Loss
Eating Disorders
Sleep Disturbances
Attention/Focus Concerns
Other
Please describe the reason for seeking counseling and any specific concerns or goals you have.
*
Are counseling services required by a state agency?
*
Please Select
Yes
No
Is the client currently in Foster Care?
*
Please Select
Yes
No
Submit Intake Form
Should be Empty: