TWS Behavioral Health Services
PRP Interest Form
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender Identity
Please Select
Female
Male
Non-Binary
Social Security Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Type of Insurance do you have
Are you in any immediate danger
Please Select
Yes
No
(If yes, list details below and what interventions were used.)
What do you wish to accomplish with the use of our services
How did you about Therapeutic Wellness Services
Google
Counselor
Advertisement
Social Media
Previous client
Other
Do you currently have a Mental Health Provider?
*
Please Select
Yes
No
If yes what is the name and address of your provider
Prior Treatment History/ Hospitalizations (Name or Provider and Dates of Service)
Are you taking any prescribed medications?
Please Select
Yes
No
If yes, List of Medications
Have you already been diagnosed with Psychological/Emotional Problems?
Please Select
Yes
No
If yes, what is your Diagnosis?
Do you receive PRP services?(Psychiatric Rehabilitation Program)
Please Select
Yes
No
Are you interested in PRP services?(Psychiatric Rehabilitation Program)
Please Select
Yes
No
Do you have a PRP Counselor that you want to work with?
Please Select
Yes
No
If yes, what is their name?
Do you have and Medical Problems
Please Select
Yes
No
Do you have a Primary Care Physician?
Please Select
Yes
No
Do you have any physical limitations?
Please Select
Yes
No
If yes, please explain
Do you use any of the following
Cane
Walker
Require Oxygen
Assistive Equipment
I do not use any of the above
Marital Status
Never Married
Seperated
Married
Divorced
Widowed
Race (Optional)
Any Children under 18?
Please Select
Yes
No
If yes, list ages
Highest grade level completed
GED
Please Select
Yes
No
Smoker
Please Select
Yes
No
If so, age of 1st use?
How many per day?
Do you have any alcohol or gambling problems?
Please Select
Yes
No
Any arrests in the past 12 months?
Please Select
Yes
No
Any Open or Pending Chargers?
Please Select
Yes
No
Are you on Parole or Probation?
Please Select
Yes
No
If yes, For what & for how long?
Submit
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