Flip the Switch Counseling Intake

Flip the Switch Counseling Intake

Enhanced online intake form for client information, service matching, safety screening, and consents. Please complete all applicable questions; fields are optional unless clearly required.
Client & Contact Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
City / State / ZIP

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Name / Pronouns
Preferred Contact Methods
Can FTS leave a voicemail?
Can FTS send text reminders?
Parent / Guardian Name
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Insurance & Payment
Primary Insurance
Primary Insurance Member ID
Secondary Insurance
Secondary Insurance Member ID
Policy Holder Name

First NameMiddle NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Insurance / Payment Options
Reason for Seeking Services
What brings you to Flip the Switch Counseling at this time?
Main concerns you want support with

Other
If other, please describe your main concern
Service interest

Other
How long has this concern been going on?
What has helped before?
What has not helped?
Prior & Current Services
Have you received counseling or support services before?
If yes, where and when?
Are you currently working with any other provider?
Current Provider Name
Current Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Prior mental health diagnosis?
If yes, please list prior mental health diagnoses
Prior mental health hospitalization?
If yes, when?
Currently prescribed medication?
Medication Name / Prescriber
Allergies or medical concerns FTS should know
Substance Use & Recovery
Current alcohol, marijuana, or other substance use?
Currently in recovery?
Have substances caused problems at home, school, work, court, or relationships?
Need support with relapse prevention or recovery goals?
Substances / frequency
Recovery supports currently involved
Safety & Risk Screening
Are you currently feeling unsafe?
Thoughts of hurting yourself recently?
Thoughts of hurting someone else recently?
Recent self-harm?
Access to weapons or unsafe items?
Domestic violence, threats, stalking, or coercion?
Recent overdose, withdrawal risk, or medical safety concern?
Immediate safety plan needed today?
If yes to any safety item, please explain what would help you stay safe today.
Strengths, Supports & Motivation
Who supports you?
What are your strengths?
What motivates you to make change?
Court / Agency Involvement
Court / DCF / School / Agency Involvement

Other
Agency / Contact Person
Phone / Email for Agency or Contact
Case Number
Are you requesting letters, attendance verification, or progress reports?
If yes, what is needed?
Deadline

MonthDayYear
Date
Hour MinutesAM/PM Option
Service Matching & Preferences
Appointment Type Preference
Provider Gender Preference
Language Preference
If other language, please specify
Preferred days
Preferred times
Transportation concerns
Accessibility needs
Goals & Expectations
What would success look like after 30 days?
What would success look like after 90 days?
What do you want your provider to understand about you before the first session?
Signatures / Internal Use
Client Signature
Client Signature Date

MonthDayYear
Date
Parent / Guardian Signature
Parent / Guardian Signature Date

MonthDayYear
Date
Printed Name of Person Completing Form
Relationship to Client
FTS Staff Reviewer / Intake Coordinator
Date Reviewed

MonthDayYear
Date
Should be Empty:

Flip the Switch Counseling Intake

Client & Contact Information

Insurance & Payment

Reason for Seeking Services

Prior & Current Services

Substance Use & Recovery

Safety & Risk Screening

Strengths, Supports & Motivation

Court / Agency Involvement

Service Matching & Preferences

Goals & Expectations

Signatures / Internal Use