WS Appointment Request Form

1
I understand that Wellness Solutions provides ONLINE TELEHEALTH counseling, coaching & psychotherapy. WS does NOT provide in person services.* This field is required.*If you are a client who would like to use insurance please be aware that insurance DOES cover telehealth sessions. Please contact your insurance company if you have additional questions regarding your insurance policy. Please choose YES to indicate that you understand and acknowledge that WS is offering telehealth services ONLY at this time. If you choose NO your appointment request will not proceed through the intake process.
YESNO
2
Who is requesting this appointment?* This field is required.Please be aware that due to privacy and confidentiality reasons an adult client is required to request and schedule his/her/their appointments and may not have another individual request an appointment on one's behalf. Also, only parents can schedule appointments for minors. Support system members, such as, grandparents and step-parents are not permitted to request and schedule appointments for a minor. WS will not accept intake requests for adults who do not take responsibility for their care and have others complete their forms.
The adult client is completing this form.
The adult client's legal guardian is completing this form.
The minor client's mother is completing this form.
The minor client's father is completing this form.
3
Name of Individual Requesting AppointmentName of parent or guardian requesting an appointment. Due to privacy reasons adults must request appointments for themselves. Spouses and other support system members may NOT request an appointment for an adult client. Please provide the fist and last name of the individual requesting the appointment below.
First Name
Last Name
4
Phone Number of Individual Requesting AppointmentThis phone number should be where WS staff can communicate privately and securely regarding scheduling and other communications. Please provide a phone number that is private and WS staff may leave a message and can receive text messages.
Area Code
Phone Number
5
Relationship of Individual Requesting Appointment to the ClientDescribe your relationship type to the client. For example: Material/Paternal Grandparent with custody of the client.
6
Email of Individual Requesting Appointment: This email should be where WS staff can communicate privately and securely regarding scheduling and other communications. Please provide the email of the individual requesting the appointment.
example@example.com
7
Address of Individual Requesting AppointmentPrimary address of the individual requesting the appointment.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Client Name* This field is required.Who is the appointment being scheduled for? Please provide the client's first and last name below.
First Name
Last Name
9
Client's Initials* This field is required.Please enter the client's initials below.
10
Client Phone Number* This field is required.This phone number should be where WS staff can communicate privately and securely regarding scheduling and other communications. Please provide a phone number that is private and WS staff may leave a message or communicate via text. Please use the following format XXX-XXX-XXXX. WS sends text messages throughout the intake process to update clients on their admission. This is the number WS will use for client communications.
11
Client Email* This field is required.This email should be where WS staff can communicate privately and securely regarding scheduling and other communications. Please provide the email of the client or client representative below. WS sends email messages throughout the intake process to update clients on their admission. This is the email WS will use for client communications. Please check your email for communications from WS. All email communications from WS will have WS in the subject line. All email communications regarding the intake process will be from the following email address: Admin@wellnesssolutionsllc.com.
example@example.com
12
Client Date of Birth * This field is required.Please enter the client's date of birth in the following format XX/XX/XXXX. Please be aware that WS provides care to clients who are 13 years of age and older. WS does NOT accept clients who are younger than 13 years old.
13
Client Primary Address* This field is required.Please provide the client's primary address below.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Is the client between the ages of 13-17 years of age?Please indicate YES if the client is between the ages of 13-17 years of age. Please indicate NO if the client is 18 years of age or older. WS accepts clients who are 13+. WS does not accept clients younger than the age of 13.
YESNO
15
Is the client a minor or adult subject to a custody order, custody decree, adoption decree, or guardianship order?Please indicate YES if the client is a minor or if the client is an adult who is subject to a custody order, decree, or guardianship. Please indicate NO if the client is not a minor or adult who is subject to a custody order, decree, or guardianship.
YESNO
16
Important Information Regarding Minor Clients or Adult Clients with Guardianship: I understand that ALL minors and adults under guardianship are REQUIRED to provide the FULL and COMPLETE CUSTODY ORDER / CUSTODY DECREE / ADOPTION DECREE / GUARDIANSHIP ORDER that has been SIGNED BY A JUDGE, INCLUDES ALL PAGES, & is DATED. This includes ALL addendums and updates. This information is REQUIRED PRIOR TO ADMISSION. These requirements are mandated by Texas State Law. WS will verify the identity of all individuals completing intake documents and providing consent for treatment prior to the first appointment.To indicate agreement and understanding with this policy please choose YES. If you do not agree or understand with this policy please check NO. Individuals who do not indicate YES will void their appointment request.
YESNO
17
Important Information Regarding Minor Clients or Adult Clients with Guardianship: I understand that all minors and adults under guardianship are REQUIRED to have BOTH PARENTS (or guardians) complete the WS Consent Registration Form. If you have any reason to believe that one parent will not sign the WS Consent Registration Form we strongly recommend that you contact that parent prior to completing this appointment request. WS will NOT accept a new client without BOTH PARENTS (or guardians) completing the WS Consent Registration Form. WS is required by Texas State Law to ensure that minors who admit to outpatient non-emergent healthcare treatment have the consent of their parents.To indicate agreement and understanding with this policy please choose YES. If you do not agree or understand with this policy please check NO. Individuals who do not indicate YES will void their appointment request.
YESNO
18
Appointment Request Type: Current Client, New Client, or Readmitting Client* This field is required.Please choose from the drop down menu below.
Current Client
New Client
Readmitting Client (It has been 2 months or more since your last appointment.)
19
Service Request Type: Individual, Couples, Family or Group* This field is required.Please choose from the drop down menu below.
Individual Counseling & Psychotherapy
Couples Counseling & Psychotherapy
Family Counseling & Psychotherapy
Group Counseling
Coaching
Advocacy
20
Clients requesting couples or family counseling: Please be aware that since every member of the couple or family will be considered a client then all members of the couple or family will need to complete the intake documents each in order to schedule an appointment. For both members of a couple or all members of a family, WS is required to maintain a complete and separate chart which means that each individual identified as participating in care must complete all intake forms.Please indicate that you understand this message by choosing YES. If you indicate that you do not understand by choosing NO your appointment request will not continue through the intake process.
YESNO
21
Clinical Staff Preference: Would you like to request a specific WS clinician? We make every effort to address a client's preferences for care. We also match a client's specific needs, schedule, and requested services with the areas of expertise and availability of our clinical staff. If you request a specific clinical staff member and we are not able to provide an appointment with your preference then we will inform you of the options available. If you indicate you do not have a preference or first available then we will also inform you of the options available prior to scheduling an appointment. We will also take your insurance payer source preference into account when offering you an appointment with our clinical staff. Our clinical staff are in VERY high demand. Please be aware that WS does not wait list clients. If you prefer not to schedule with the options provided then the appointment request will expire. * This field is required.Please choose from the drop down menu below.
Danielle C. Ellis MA MCJ LPC NCC
Jason Stewart LPC
No Preference
First Available
22
Preferences for Care: Do you have any specific preferences for your care? For example, would you prefer mindfulness-based skills or are there specific skills/types, or expertise of the clinical staff you would like to request? If you do not have any preferences for care please type N/A below.* This field is required.Please provide a brief reply below.
23
Appointment Availability* This field is required.Please click on ALL appointment spots convenient to your schedule for consistent weekly appointments. The more availability you are able to provide the more likely we are to provide an appointment within 7 days. Appointments that are 3 PM and later Monday-Friday and appointments on the weekends are the most requested times which may result in scheduling delays. We use this information to determine if WS can offer a first available appointment. If we are not able to offer an appointment based on your schedule or other factors the appointment will automatically expire after 14 days. WS will accept two new client appointment requests per year. The more availability a client provides the more likely they will obtain an appointment.
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How did you hear about WS? Are you a referral from a current or former client? Are you a referral from a trusted referral source such as another clinician, facility, school, or friend of WS? What made you choose WS? WS gives preferential scheduling to referrals from current or former clients and trusted referral sources so please let us know if this is the case.* This field is required.Please provide a brief reply below.
25
Part 1: The Following List of Symptoms, Concerns, & Stressors Are Common Reasons For Seeking Counseling, Coaching, & Psychotherapy. Please Choose ALL That Apply To You.* This field is required.Please select ALL that apply. (Please review the WS website for a list of all of the symptoms and presenting concerns that WS provides care for and those that are excluded from the care that we provide.)
ADD / ADHD
Abuse (Victim)
"Adulting" & Life Skill Stress
:) All The Things :)
Anxiety
Assistance With A "Life Make Over"
Autistic Spectrum / Neuro-Diverse
Bipolar / Mood Instability
Breaking Free Of Family Cycles Of Dysfunctional / Unhealthy Behaviors - "Cycle Breaking"
Boundary Setting / Codependency
Caregiver Fatigue
Commitment Difficulty
Concerns Related To Being A Current Student
Conflict Resolution Communication Skills
Controlling / Dominating Behaviors
COVID-19 Related Anxiety / Complications
Cultural Concerns
Current Or Previous Employment With Law Enforcement, Fire Department, or First Responder
Current Or Previous Military Service
Currently Under The Care Of A Physician For Psychiatric Medication Management
Custody Evaluation*
Daydreaming
Dealing With Difficult / Problematic People
Death Of A Loved One In The Past 12 Months
Death Of A Loved One By Suicide (In The Past 12 Months)
Death Of A Loved One By Suicide (1+ Years Ago)
Depression
Delusions
DBT Specialty Treatment - Dialectical Behavioral Therapy
Difficulty Coping With Adjustment To Life Changes
Developing Coping Skills & Strategic Life Planning Skills
Difficulty Getting Out Of Bed
Difficulty Functioning & Taking Care Of Age Appropriate Responsibilities
Difficulty Identifying Strengths Or Positive Qualities
Difficulty Making Future Orientated Plans
Difficulty Meeting Deadlines
Difficulty Loosing Track of Time / Always Feeling Rushed
Difficulty Organizing One's Self
Difficulty With Attention, Focus, Concentration, Or Memory
Difficulty Coping with Uncertainty
Difficulty Making Decisions / Healthy Decision Making
Disassociated Feelings & Symptoms
Domestic Violence (Victim)
Eating Concerns / Food Concerns
Educational and/or Career Counseling
Education Concerns
Effective Communication Skills
Emotional Sensitivity - Feelings May Easily Be Hurt
Emotional Reactivity - It does not take much to cause a strong emotional reaction.
Employment Concerns
Exploring Possible Divorce / Should I Stay Or Should I Go
Family Concerns
Feeling Excessive Fatigue Despite A Full Night Of Rest
Feeling Overwhelmed
Feeling Worthless
Feelings of Being a Burden to Others
Feelings of Unworthiness
Feelings of Hopelessness & Helplessness
Financial Concerns
Frequent Thoughts of Death & Dying
General Life Dissatisfaction
Grief / Bereavement
Hallucinations
Healthy Relationship Skill Development
Housing Concerns / Recent Move
Hyper-Sensitivity To Feedback
Impulsive Behavior
Inpatient Mental Health Treatment In The Past 12 Months
Indecisiveness
Insight Development
Insomnia
Interpersonal Relationship Skill Development
Intrusive Thoughts
Irritability
Jealousy
Lying For No Reason
Lack of Compassion / Empathy For Others
Lack of Positive Goals or Plans for the Future
Lack of Recreational or Leisure Activities
Legal Concerns
Loss of Interest in Activities that You Previously Enjoyed
Medical Concerns Influencing Coping Skills
Meditation & Relaxation Skills
Mindfulness Skills
Moody
Nightmares
OCD
Panic Attacks / Anxiety Attacks
Parent / Child Relationship Concerns
Paranoia
Passive Aggressive Behavior - Coping With This Symptom In Others
Passive Aggressive Behavior - Received Feedback That This Is How You Relate To Others
Passivity - Lack Of Assertiveness Leads To Problems In Your Life
Perfectionism
Personality Disorder
PTSD
Poor Self-Image
Recent Loss of a Pet
Relationship Concerns
Religious Concerns
Rigid / Inflexible Behaviors
Ruminating Thoughts (Thinking about the same thing repeatedly as if the thought is stuck repeating)
Self-Centeredness
Self-Confidence
Self-Esteem
Stress Management
Stalking (Victim)
Self-Injury
Sexual Abuse (Victim)
Sexual / Intimacy Concerns
Sexual Orientation / Gender Identity
Shoplifting
Substance Abuse / Chemical Dependency
Suicide Attempt In The Past 12 Months
Suicidal thoughts
Supportive Constructive Feedback
Transportation Concerns
Tic Disorder
Trauma Recovery
Tourette Disorder
Value Identification
Victim / Survivor of Trauma and/or Crime In The Past 12 Months
Withdrawn
Work Concerns
Work Life Balance
26
Part 2: The Following List of Symptoms, Concerns, & Stressors Are Common Reasons For Seeking Counseling, Coaching, & Psychotherapy. Please Choose ALL That Apply To You.Please Select ALL That Apply. (Please review the WS website for a list of all of the symptoms and presenting concerns that WS provides care for and those that are excluded from the care that we provide.)
Abuse (Perpetrator)
Aggressive Behavior
Anger Management
Court Ordered Parenting Classes
Court Room Testimony
Court Ordered Treatment
Custody Evaluation
Domestic Violence (Perpetrator)
Educational Testing
Gambling
Homicidal Thoughts or Behavior (Current or Previous)
Interactions with the Legal System
Neuropsychological Testing
Return to Duty Evaluation for Law Enforcement
Sexual Compulsive Behavior / Sexual Addiction
Sexual Abuse (Perpetrator)
Social Security Disability Evaluation
Stalking- Current or Previous (Perpetrator)
27
WS is sensitive to our client's privacy, confidentiality, and safety concerns. Do you have special requests or concerns regarding privacy and confidentiality? For example, many clients who seek our services have not shared that information with members of their families, spouses, or are trying to leave a domestic violence situation and have safety concerns. We understand the need to respect your privacy and ensure your safety while making healthy changes in your life. We are committed to providing our clients with discretion, privacy, and confidentially in order to ensure safety.* This field is required.Please choose YES to indicate if you have a special request for privacy and confidentiality concerns. Please choose NO to indicate that you do not have any special requests regarding privacy and confidentiality at this time.
YESNO
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Please provide us additional information regarding your request regarding privacy, confidentiality, and safety concerns. We want to be attentive to your specific needs and preferences so that you feel comfortable and safe to engage. If you do not have any additional information to provide you can state N/A.
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I understand that WS does not accept new clients or participate in clinical cases where there are interactions with the legal system, contested custody of minors, court-ordered treatment, required treatment due to job jeopardy, involvement with Child Protective Services (CPS), involvement with Adult Protective Services (APS), disability determination, short term disability insurance determination or coverage, or documentation for the Family Medical Leave Act (FMLA) determination or coverage. Wellness Solutions, LLC does not provide information, documentation, communication, intervention, treatment planning, or any form of participation in the aforementioned activities. WS does not provide services for Substance Abuse Professional (SAP) evaluations. For clients who are seeking these types of services or similar services, it is advised that the client contact WS to ensure that the client is eligible for services. Should one of the aforementioned services become a presenting issue at any time throughout the client's care then WS reserves the right to discharge the client. With my initials below I submit that I understand and agree to this policy.* This field is required.
Clear
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HIPAA: Proof Of Identity Of The Individual Completing This FormThis information is required for appropriate identity verification.
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HIPAA: Proof Of The ClientThis information is required for appropriate identity verification.
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Signature* This field is required.With my signature below I give WS permission to use the contact information provided in order to begin the appointment scheduling process. I understand that the submission of an appointment request is not a guarantee of an appointment. I also understand that I will not be scheduled for an appointment if any clinical intake documents or information have not been provided to WS. I understand that information must be provided in an honest and transparent manner. Any information provided falsely may result in WS refusing to provide services. Please sign the below request.
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Unique ID
Should be Empty: