360 Talk Therapy – New Client Inquiry & Intake Screening
Complete this brief 5–7 minute screening to help match you with the right provider and confirm next steps.
Referral / Contact Information
Date of inquiry
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral source
*
Please Select
Psychology Today
Google/Search
Insurance Directory
Provider Referral
Friend/Family
Social Media
Returning Client
Other
Psychology Today profile or provider requested
Caller is
*
Please Select
Client
Parent/Guardian
Spouse/Partner
Case Manager/Social Worker
Other
Client full legal name
*
First Name
Middle Name
Last Name
Preferred name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Pronouns
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred contact method
*
Please Select
Phone
Text
Email
Permission to leave voicemail
*
Yes
No
Permission to send a text identifying 360 Talk Therapy
*
Yes
No
Best time to contact
City and state
*
What Are You Looking For?
Service Requested
*
Individual Therapy
Couples Therapy
Family Therapy
Child/Adolescent Therapy
Medication Management / Psychiatric Evaluation
Therapy + Medication Management
Group Therapy
Not Sure
Main Reasons for Seeking Help
*
Anxiety
Depression
Stress/Burnout
Trauma/PTSD
Grief/Loss
Relationship Concerns
Family Conflict
ADHD/Attention Concerns
Anger
Mood Changes
Sleep Problems
Life Transition
Work/School Concerns
Substance Use Concerns
Chronic Illness/Caregiver Stress
Other
What would you most like help with right now?
*
How soon are you hoping to begin?
*
ASAP
Within 1 week
Within 2 weeks
Within 1 month
Flexible
Preferred Therapist or Provider (if any)
Therapist Preferences (optional)
Gender preference
Specialty preference
Language preference
Other
Safety / Urgency Screening
Are you in immediate danger or experiencing a medical or psychiatric emergency right now?
*
Yes
No
Have you had thoughts of suicide or seriously harming yourself recently?
*
Yes
No
Have you had thoughts of seriously harming someone else recently?
*
Yes
No
Have you had a suicide attempt or emergency psychiatric hospitalization in the past 30 days?
*
Yes
No
Are you currently feeling severely confused, having hallucinations, or unable to care for your basic needs?
*
Yes
No
Clinician review required?
Yes
No
Staff notes
Insurance / Payment Screening
Insurance coverage and benefits must be verified; submission of this form does not guarantee coverage or authorization.
Payment method
*
Please Select
Insurance
Self-Pay
EAP
Not Sure
Insurance company name
Plan type
Please Select
HMO
PPO
Medicaid Managed Care
Medicare
Other/Unknown
Are you the policyholder?
Please Select
Yes
No
Unknown
EAP authorization / session information
Would you like a benefits verification before scheduling?
Yes
No
Staff-only self-pay discussion completed?
Please Select
Yes
No
Not Applicable
Scheduling / Access
Preferred visit type
*
Telehealth
In-Person
Either
General availability
*
Weekday Mornings
Weekday Afternoons
Weekday Evenings
Saturday
Flexible
Preferred days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Accessibility or accommodation needs
Language or interpreter needs
Telehealth location confirmation
*
Yes
No
Not sure
Brief Treatment History
Have you participated in therapy before?
*
Yes
No
Are you currently seeing another therapist or psychiatric provider?
*
Yes
No
Are you currently taking psychiatric medications?
*
Yes
No
Prefer not to say
Have you had any psychiatric hospitalization in the past 6 months?
*
Yes
No
Prefer not to say
Anything else you'd like us to know before matching or scheduling?
Contact / Scheduling Outcome
Intake Status
*
Please Select
New Inquiry
Needs Clinician Review
Insurance Verification Needed
Ready to Schedule
Scheduled
Waitlist
Referred Out
Unable to Reach
Not a Fit
Declined Services
Assigned Therapist / Provider
Appointment Date and Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Follow-Up Needed By
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-Up Method
Please Select
Phone
Email
Text
Portal Message
In Person
Other
Number of Contact Attempts
Disposition / Referral Notes
Acknowledgment
Acknowledgment Statements
*
I understand this inquiry form is for screening and scheduling and is not a substitute for a full clinical assessment.
I understand submitting this form does not establish a therapist-client relationship until services are formally accepted and initiated.
I consent to being contacted by 360 Talk Therapy using the communication preferences selected above.
Completed by
*
Prospective client
Staff by phone
Electronic Signature
Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Name / Initials
First Name
Last Name
Submit
Submit
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