Today's Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Full Name:
*
Client's Date of Birth:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number:
*
Email
*
example@example.com
SSN #
###-##-####
Parent Name (if client is a minor)
First Name
Last Name
Parent Phone Number (if client is a minor)
-
Area Code
Phone Number
Parent Email (if client is a minor)
example@example.com
Parent Address (if client is a minor)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Transgender
Other
Ethnicity
*
African American
White
Hispanic or Latino
Prefer Not To Say
Other
Is the client over 18 y/o:
*
YES
NO
Emergency Contact Name:
Emergency Contact Phone Number:
Emergency Contact Relationship
Client's Address:
Street Address
*
City,State,Zipcode:
*
If Patient is a Child Please Enter Parent/Guardian Name:
*
If not applicable enter N/A
Parent/Guardian Date of Birth:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent Guardian Phone number #:
Parent/Guardian Address,City,State,Zipcode:
SERVICES REQUESTED
MENTAL HEALTH/ THERAPY
SUPPORTED EMPLOYMENT
PRP (PSYCHIATRIC REHABILITATION PROGROM SERVICES)
MEDICATION EVALUATION /MANAGEMENT
MENTAL HEALTH EVALUATION
EARLY INTERVENTION
DWI/DUI
ESA DOCUMENTATION/LETTER ( EMOTIONAL SUPPORT ANIMAL)option 8
Other
Reason(s) for Referral (CHECK ALL THAT APPLY):
*
Depression/Anxiety
Post-partum Depression/Anxiety
Trauma
Anger Management
PTSD
Behavioral Issues/ School Problems
Substance Abuse
Self Esteem Issues
Unhealthy Coping Skills and Mechanisms
Suicidal/Homicidal Ideations
Family Conflict
Grief/Loss
Infertility/Postpartum/Pregnancy Maternal Related Mental Health
Other
If Other is Selected Briefly Explain:
Current Medications :
Insurance/Billing Information:
Self-Pay
*
YES
NO
Insurance:
*
YES
NO
Medical Assistance:
*
YES
NO
Insurance Name:
*
If question is not applicable enter N/A
Insurance Policy Number:
*
If question is not applicable enter N/A
Insurance Group Number:
*
If question is not applicable enter N/A
Policy Holder Name and Date of Birth:
*
Medical Assistance Number:
*
If question is not applicable enter N/A
Are you utilizing EAP (Employee Assistance Program) benefits?
*
YES
NO
If Yes What EAP Benefits will you be using:
*
Compsych EAP
Aetna EAP
Wellspring EAP
Cigna EAP
N/A
Are you in need of assistance with a work or a school claim or leave ?
Yes
No
Do You need any special accommodations
hearing impaired
vision impaired
interpreter
wheelchair accessibility
Other
If other accommodation please explain
Attach PICTURE of Front and Back of Insurance Card & any additional information:
Browse Files
Cancel
of
Who Referred You / How did You hear about us? (Ex. Self, Insurance Company, Job...)
*
Submit
Should be Empty: