Client History Form
This form is used to collect information about your presenting issue. This help us match you with the most suitable therapist for you. Once completed we will schedule your appointment and provide this to your therapist.
Is this being filled out for
*
Myself
Couples Therapy
My Child
Other
Briefly describe why you are seeking therapy today?
This can be as long or as short as you want to share with us. This will help us find you the best therapist for treatment.
Briefly list any prescribed any medications for mental health concerns, including hospitalizations and/or previous therapy.
If none, type N/A or None
Have you had any suicide attempts within the past 6 months?
Yes
No
I have had suicidal ideations within the past 3 months
Name
*
First Name
Last Name
What state are you located in?
If doing couples therapy, please provide the name of your partner.
Partner's First Name
Partner's Last Name
Partner's Phone Number
Please enter a valid phone number.
Partner's Email
example@example.com
Partner's Date of Birth
-
Month
-
Day
Year
Date
Insurance Type
Medicare
Aetna
BCBS
Cigna
Beacon
Horizon
Let us know what days and times work best for your appointment.
*
If you have multiple openings in your schedule, please let us know. It will allow for more booking options on our end. Thank You!
What is your preferred way of communication?
*
Phone Call
Text
Email
All of the Above
Submit
Once this completed, look out for the Welcome E-Mail
Should be Empty: