Client Interest & Referral Form
Complete this form if you are referring a client or if you are seeking out services for yourself or someone you have legal guardianship over. This information will help us with provider fit, plan client care needs, and verify insurance coverage.
Client's Legal Name
*
Prefix
First Name
Middle Initial
Last Name
Suffix
Client's Preferred Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Sex Assigned at Birth
Please Select
Male
Female
Unknown
Client's Gender Identity
Please Select
Male
Female
Non-binary
Trans Woman
Trans Man
Prefer not to say
Other
Client's Spoken Language(s)
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Primary Contact Phone
*
Format: (000) 000-0000.
Client or their Legal Guardian's Email
*
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.
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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Cancel
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Therapy Setting Preference
In-Person (Berlin Heights, Ohio Office)
School-Based (Margaretta Local School District)
School-Based (Townsend Community School)
Virtual/Telehealth
Reason for Services
*
Please provide a brief description regarding what is happening or current stressors leading to seeking out therapy services at this time.
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: