New Client Paperwork

New Client Paperwork

This overview explains the purpose and contents of this form. It is to be completed once you have been assigned a provider and given an appointment date.
Overview:

Before you begin, here’s a quick overview of what this paperwork includes:
- Demographics – Your contact information, emergency contact, and communication preferences (including text reminder consent).
- Clinical Information – Brief health history and reason for seeking services.
- Employment / School Information – Employer details for adults, or school information for minors/students.
Why this matters:

Completing this form ensures we have accurate information to provide you with safe, effective, and seamless care. This allows your provider to gain a clearer understanding of your needs and background before meeting with you, making your first session more focused and effective.

Important Information

NOTES FOR MINORS & TIPS FOR COMPLETING FORMS
Minors:

Parent/Guardian (Please Read)

A legal guardian must be present at the first appointment for all clients under the age of 18, unless instructed otherwise by NHCC office staff.

Some providers may prefer that the first session be attended only by the guardian (without the minor present), with the minor joining at the following appointment. Our office staff will inform you of this requirement at the time of scheduling if it applies to your situation.

Tips for Completing this Form:
Tips for Completing This Form:
- Please answer all questions accurately to help us provide the best care.
- If you have insurance, have your card ready for upload if you have not done so already in our NEW CLIENT INTAKE REQUEST FORM.
- If you have questions, call us at (337) 478-1411.
  - Due to high call volumes, please note that we only return calls when a voicemail is left. Missed calls without a message will not receive a callback.

Important: Provider-Specific Paperwork Explained (Click to Expand)
If you are, or plan to be, scheduled with more than one provider at NHCC - please expand the 'Important Note - Multiple Providers' section below and review it carefully before continuing.

NOTES FOR MINORS & TIPS FOR COMPLETING FORMS
At New Horizons Counseling Center, LLC (NHCC), each provider is individually contracted and responsible for maintaining accurate, provider‑specific records.

For this reason, NEW CLIENT PAPERWORK must be completed separately for each NEW provider you begin services with.

This process is not meant to inconvenience you—it is a matter of ethical responsibility and compliance. Each provider has unique forms and requirements that ensure:
- Your care is documented correctly under the provider you are seeing.
- Confidentiality and HIPAA standards are upheld.
- Billing, insurance, and clinical records remain accurate and provider‑specific.
- You receive services that are tailored to the scope of practice of the provider (e.g., counseling vs. medication management).
Completing paperwork again when scheduled with a different provider protects both you and your provider by ensuring that all information is complete, current, and ethically aligned with professional standards.

Demographic Information

This section gathers your basic identifying details and emergency contact information.
Client Name:*

First NameMiddle NameLast Name
Client DOB:*

MonthDayYear
Date of Birth
Email*
Please enter a valid email.
Phone Number:*
Please enter a valid phone number that our office can reach you at via phone call or text message from our secure phone system.
Authorization for Secure Text Messaging:*

Yes - I authorize text messages for reminders and follow‑up.No - I do not authorize (I understand I will NOT receive text reminders or follow‑up texts)

Emergency Contact
We require an emergency contact to ensure your safety. In the event of a medical or mental health crisis during services, our staff must have a designated person we can reach quickly. This helps us provide appropriate support and keep you safe.
Please provide at least one emergency contact. Add additional contacts if desired.*

Additional Reminder Contact - (Optional)
OPTIONAL: Provide extra contact details if reminders should go to more than one party. If left blank, all communications will default to the primary phone number listed above.

Note: We can only store up to 2 reminder text phone numbers. To change or update a number later, please contact our office directly.

PLEASE READ: By entering this information below, I give New Horizons Counseling Center, LLC permission to send reminder texts to me (primary phone number) and the number listed below. I understand and acknowledge the information provided.
Additional Reminder Contact Information:

Employment / School Information

Please complete the section that applies to you. Adults provide employer details. Minors or students provide school information.
📌Informational Note📌

This section is for informational purposes only. No employment or school information will be released unless you have provided explicit verification and authorization for us to do so.
Which information applies to the client?*

Adult – Employment InformationMinor/Student – School Information
Employment Status

Employed Full‑TimeEmployed Part‑TimeSelf‑EmployedUnemployedStudentRetiredOther (please specify)
Current Employment Information:
School Information:

Additional Demographic Information

If you already completed the New Client INTAKE Request Form, you can select 'Yes' and skip this page.
Have you already completed our - NEW CLIENT INTAKE REQUEST FORM - before scheduling your appointment or receiving this form?*

YesNoI'm not sure.
Please Read before Uploading:

If you have not already uploaded a copy of your Driver’s License or State‑issued ID (or your legal guardian’s ID if the client is a minor) to us, please upload it below.

If the client is a minor, please upload the legal guardian’s Driver’s License/ID instead.

If this is not received in advance, you will be asked to provide it at your first appointment before sessions can begin.

Demographic Information Needed
Client Gender:*
Social Security #:
Optional: Providing your Social Security Number helps us verify insurance coverage and process claims accurately.
Address (Mailing)*

Street Address

CityState

Zip Code

Insurance Information:
Do you have insurance?*

YesNo, I will be SELF PAY
Primary Insurance: *
If you do not see your insurance, please select Other.
OTHER Insurance Name:
Member ID/Policy# (Primary)*
Please enter your Member ID/Policy# as shown on your insurance card.
Policy Holder (Primary)*

SelfOther
Policy Holder - Relationship to Client:*
Primary Insurance
Policy Holder Name:*

First NameLast Name
Policy Holder DOB:*

MonthDayYear
Date
Policy Holder SSN#: (if applicable):
Do you have secondary insurance?*

YesNo
Secondary Insurance:
Policy Holder (Secondary)*

SelfOther
Member ID/Policy# (Secondary)
Please Read before Uploading:

If you have not already uploaded your insurance card(s) in the New Client Intake Form, please upload clear copies of both the front and back below.

If not applicable at this time, a copy of your card(s) will be required at your first appointment before services can be provided.

Family Members – In Household vs. Outside Household

Please list all family members who currently live in your household, as well as immediate family members who do not live in the household.
Please list family members IN the household and their relationship to you.
List immediate family members NOT in the household.

Biopsychosocial History

This section gathers background information about your life, health, and experiences to help us understand your needs.
Presenting Concerns: (Please see example below if needed)
Symptoms Checklist (Please do NOT leave blank)*
Prior Psychotherapy, Counseling, Inpatient Stays? *

Family Psychiatric History?*

Medical Information (continued)

Please provide the following information in regards to the client. If a child is the client, please complete the form for your child.
Are you currently on any medications?*

YesNo
Please list all medications and the dosages you are currently taking.
Primary Care Physician (PCP):
Permission to contact PCP, if needed?

Yes, permission grantedNo, permission denied
Please list below your GOALS, STRENGTHS, MOTIVATION, etc.*
Also, do you have family support and is your spouse (if applicable) willing to meet with the counselor in order to improve your therapy?

Credit Card Payment Authorization:
*** We have created this form to reduce balances on accounts and No-Show Fees. Co-payments are due upon appointments check in. ***

I AUTHORIZE/DO NOT AUTHORIZE NEW HORIZONS COUNSELING CENTER:
to charge this card for any future appointments that I may owe for, once I check in (ex. Your copay or if your were to have a phone session and need to make a payment towards your account).to charge this card $60.00 for any future NO SHOWED appointments, in the case that I do not call the office ahead of time to cancel a scheduled appointment and do not show up for it. If payment is made for a NO SHOW, any future appointments will be kept scheduled.I DO NOT authorize New Horizons Counseling Center to keep a card on file; however, I do understand that if I NO SHOW 2 appointments in a row, I will not be seen again until my fee(s)are paid for or I speak with my provider to explain why I was not able to attend appointment(s). I also understand, if I owe the office a copay that is not being paid, after 3 unpaid sessions I will not be able to schedule another appointment until I make a payment towards my balance.
CREDIT CARD TYPE:*

MASTERCARDVISADISCOVERAMEX
CREDIT CARD NUMBER:*
CARD HOLDER NAME:*

First NameLast Name
EXP DATE:*

Credit Card Payment Authorization Signature:

Clear
Today's Date:
Almost done!

Once you press Submit, you’ll be automatically transferred to the Consents page to complete the remaining paperwork.
Should be Empty:

	Year of Treatment	Type of Service	Provider/Facility (Optional)	Reason for Treatment	Outcome
1
2
3
4

	Person 1	Person 2	Person 3
Family Member
Diagnosis / Concern
Treatment History
Current Status
Impact on You

New Client Paperwork

Overview:

Important Information

New Client Paperwork

Demographic Information

Employment / School Information

Additional Demographic Information

Insurance Information:

Family Members – In Household vs. Outside Household

Biopsychosocial History

Medical Information

Medical Information (continued)

*** We have created this form to reduce balances on accounts and No-Show Fees. Co-payments are due upon appointments check in. ***

* We have created this form to reduce balances on accounts and No-Show Fees. Co-payments are due upon appointments check in. *