Psychological Services Intake

1
Your Name* This field is required.If you are completing this form on behalf of someone else, such as a minor, please enter your name here.
2
Relationship to Client* This field is required.Your relationship to the client: self, mother/father, sibling, partner...
3
Client's NameIf different from the name of the person completing this form.
4
Client's Sex* This field is required.We ask this question as insurance requires we designate sex on all claims. Our intake documents will ask about your gender identity and preferred pronouns.
Please Select
Please Select
Female
Male
Intersex
Trans
Decline to answer
5
Client's Date of Birth* This field is required.
Month
Day
Year
6
Client's Academic or Vocational Details* This field is required.If the client is in school: what grade is the client in and how is he or she performing in school? If the client is working: in what field does the client work and is employment full-time, part-time, or something else?
Huge
Large
Normal
Small
Ok
Ok
7
Concerns* This field is required.Please describe your concerns and be sure to include when these concerns first began.
Huge
Large
Normal
Small
Ok
Ok
8
Are you interested in assessment, therapy, or both?* This field is required.
Assessment
Therapy
Both
9
Phone Number* This field is required.Please enter your best contact number.
Area Code
Phone Number
10
Permission to leave a message?Do we have your permission to leave a message at the phone number entered?
Yes
No
11
Email
example@example.com
12
Please select your insurance coverage.* This field is required.
Please Select
Please Select
Aetna
Anthem/BCBS
Cigna
Medicaid
Medicare
Self Pay
Tricare/Triwest
United Healthcare/UHC/UMR
Other
13
If you have MEDICAID, please enter your MEDICAID ID number.
14
LocationWe see clients in person at offices in Fort Collins and Denver. We also see clients virtually. Which best suits your needs?
Please Select
Please Select
Fort Collins
Denver
Virtual
I'm flexible!
15
Additional InformationIf there's any additional information you would like us to know or if you have other concerns, please use the space provided to explain.
Should be Empty: