Client Interest/Referral Form
Please complete the following information to help us serve you better.
Client's Legal Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Legal Guardian's Name
Prefix
First Name
Middle Initial
Last Name
Suffix
Legal Guardian's Relationship to Client
Examples: Mother, Father, CPS Caseworker, Step-Parent with Medical Rights
CHILDREN IN ALTERNATIVE PLACEMENT or CHILDREN OF DIVORCED/LEGALLY SEPARATED PARENTS
Copy of legal guardianship paperwork such as current custody agreement, court orders, signed letter from a judge, Medical Power of Attorney, and/or Individual Child Care Agreement (ICCA) must be received at the time of intake otherwise follow up appointment cannot be scheduled until it is received, as instructed by the Licensing State Board.
Address 1
*
Address 2
City / State
*
Zip Code
*
Primary Contact Phone
*
Please enter a valid phone number where you can be reached in order to set up services.
Sex Assigned at Birth
Male
Female
Gender Identity
Please Select
Male
Female
Non-binary
Trans Woman
Trans Man
Prefer not to say
Other
Languages Spoken
Insurance Coverage
*
Please Select
Yes I have insurance and plan to use it
I do not wish to use my insurance and will be responsible for all charges myself
No I do not have insurance
Unknown if client has current coverage
Insurance Information
Upload the Front of Your Insurance Card
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Upload the Back of Your Insurance Card
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Reason for Services
*
Please provide a brief description regarding what is happening or current stressors leading to seeking out therapy services at this time.
Therapy Setting Preference
In-Person (Berlin Heights, Ohio Office)
School-Based (Townsend Community School)
Virtual/Telehealth
In-Person Session Safety Screening. Please indicate if any of the following apply to the client. Your responses are confidential and used solely to support safety and care planning needs.
Noticed bed bugs, fleas, lice, or other pests in the home or on personal belongings within the last 30 days
Had close contact with someone who has been treated for bed bugs, lice, or other pests within the last 30 days
Any current legal situations within the last 30 days involving violence (e.g., assault, domestic violence, protective orders)
Any current criminal charges related to weapons, violence, or harm to others that has occurred in the past 30 days
Currently involved in an active domestic violence situation where there is verbal, emotional, physical, sexual or financial abuse or misuse towards the client
Client is using power and control tactics or manipulation over another person
Client has had cold and/or flu-like symptoms within the last seven days
Client has been to the Emergency Room (ER) for physical or mental health care within the last 30 days
Client has current suicidal or homicidal thoughts or has engaged in self-harming behaviors; or client has had them within the last 30 days
Who referred the client or how did you hear about our services?
Other Significant Information
Please provide any additional information that you feel is important to share prior to meeting.
Questions
Are there any questions or concerns that you have regarding starting therapy services?
Submit
Should be Empty: