Olson Family Counseling — New Client Intake Request

Welcome to Olson Family Counseling

Thank you for reaching out. This form will take approximately 10-15 minutes to complete. Please answer all questions as honestly as possible so we can best match you with the right therapist. All information is kept strictly confidential and protected under HIPAA. If you are experiencing a mental health emergency, please call 911, call or text 988, or call Colorado Crisis Services at 1-844-493-8255. Do not use this form in an emergency.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Client Age Range*

Under 12 years old12 years old or older
Gender Identity*

WomanManNon-binaryTransgenderOther
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Race/Ethnicity

WhiteBlack or African AmericanHispanic or LatinoAsianNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderOther
Primary Language*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you currently reside in the state of Colorado?*

Yes, I live in ColoradoNo, I live in another state
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name and Phone Number*
What type of therapy are you seeking?*

Individual TherapyCouples TherapyFamily Therapy
Are you interested in medication management services?

Yes, I am interested in medication management servicesNo, I am not interested at this timeI am not sure, I would like more information
Insurance Provider*

ChampVAAetnaCignaAnthemBCBS (Blue Cross Blue Shield)United HealthcareUMROptumMedicaid (Health First Colorado)Self-Pay (no insurance)I am not sure or need to verify
Insurance Member ID (if known)
Do you have reliable internet access for video sessions?*

Yes, I have reliable internetNo, my internet is unreliable or unavailable
How would you prefer to conduct your intake consultation?*

Video (virtual meeting)Phone call
Do you have a specific therapist in mind?*

Yes, I have someone in mindNo, please help match me with the right therapist
Which therapist are you interested in working with?
Which days are you generally available for sessions?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What times of day work best for you?*

Mornings (before 12pm)Afternoons (12pm to 4pm)Evenings (after 4pm)
What type of therapy are you interested in? Select all that apply.

CBT (Cognitive Behavioral Therapy)DBT (Dialectical Behavior Therapy)EMDRIFS (Internal Family Systems)Mindfulness-Based TherapyTrauma-Focused TherapySomatic TherapySolution-Focused TherapyI am not sure or open to recommendations
Do you have any current or previous mental health diagnoses?
Have you been in therapy before?*

YesNo
Are you currently seeing another therapist?*

YesNo
In your own words, what brings you to therapy at this time?*
How often are you currently using alcohol or substances?*

Not currently usingMonthly or lessWeeklyDaily
Have you experienced any thoughts of suicide?*

No, I have never experienced these thoughtsYes, more than a year agoYes, within the last 6 monthsYes, within the last 3 monthsYes, within the last monthYes, within the last week
How did you hear about us?
Couples and Family Therapy Insurance Acknowledgment*

I understand that couples and family therapy may not be covered by all insurance plans. I agree to have my benefits verified before my first session and understand I may be responsible for session costs if my plan does not cover this service type.
Final Authorization Acknowledgment*

I acknowledge and agree
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Welcome to Olson Family Counseling