New Client Screening Form

New Client Screening Form

Please complete this form to request services. A member of our team will contact you within 24–48 hours.
Individual Seeking Services
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
If services are being requested for a individual under the age of 18, are you the individual's legal guardian?
If no, explain relationship.
Name and the best contact number of the person completing this form (if different from the person seeking services):
Service Needs
What services is the client requesting?

Other
What are you seeking support for? Check all that apply.

Other
Please briefly describe your current concerns and reason for seeking services.
- Preferred Days
- Preferred Time
- How would you prefer to receive services?
- Preferred clinician option
- Select clinician
- How do you plan to pay for services?
- Private Insurance
  
  Other
- Please upload a copy of the insurance card that will be used for services.
  
  Consent: By uploading, I authorize verification of benefits only.
  Cancelof
- System Involvement
- Anything we should know?
- Referral Source
- Referral Source
  
  Other
- This form is for inquiry purposes only and does not establish services.
Should be Empty:

Individual Seeking Services