New Client Screening Form

New Client Screening Form

Welcome! We're Glad You're Here.
The following questions help us learn more about the individual seeking services, understand their needs and preferences, and determine the most appropriate next steps for care.
📋 Before You Begin:
- This screening typically takes 5–10 minutes to complete.
- If you are requesting services for more than one individual, a seperate screening form must be completed for each person.
- After submitting your screening, a member of our team will typically contact you within 24-28 business hours.
- Need assistance? Email us at office@h2heartcc.com
- Information submitted through this form is transmitted securely and handled in accordance with with applicable privacy and confidentiality standards.
👩🏽‍🏫 Are you are a provider? Please complete our Provider Referral Form.

Person Completing the Form

Please provide information for the person completing this form.
Note: Individuals who are not the child's parent or legal guardian may complete this screening form; however, a parent or legal guardian will be required to provide consent before services can begin.
Your Name

First NameLast Name
Your Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email Address
example@example.com
Would you like to enter the child's parent/legal guardian's information?

Parent/Legal Guardian's Information

Please provide information for the parent/legal guardian for the child seeking services.
Parent/Legal Guardian Name

First NameLast Name
Parent/Legal Guardian Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Legal Guardian Email Address
example@example.com

Child's Information

Please provide information about the child seeking services.
Child's Full Name

First NameLast Name
Child's Preferred name
Child's Date of Birth

MonthDayYear
Child's Sex

Other
Child's Physical/Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the child's mailing address different from their physical/home address?
Child's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Personal Information

Please provide information for the person seeking services.
Full Name

First NameLast Name
Preferred name
Date of Birth

MonthDayYear
Sex

Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Physical/Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address different from your physical/home address?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance & Payment

This information is used to verify benefits, determine eligibility, and discuss available payment options.
What payment method do you plan to use for services?

Other

Which Medicaid Louisiana Bayou Health Plan do you currently have?
To help verify your Medicaid/Bayou Health Plan eligibility, please choose one of the following options:

Front of Card:

Consent: By uploading, I authorize verification of benefits only.
Cancelof
Back of Card:

Consent: By uploading, I authorize verification of benefits only.
Cancelof
Social Security Number:

Review & Submit

Please review your responses before submitting your screening form.
Important Notice:

This form is for inquiry purposes only and does not establish services, create a therapist-client relationship, or guarantee acceptance into treatment. A member of our team will review your submission and contact you regarding next steps.
Should be Empty:

Welcome! We're Glad You're Here.