The Center for Counseling Arts Online Intake

Procedure Code

Diagnoses

Therapist

First Name

Last Name

Preferred Pronouns

Parent or Guardian Full Name

(only required if a minor)

Today's Date

Selected Therapist

If your therapist is not listed above, please enter here:

What days and time are you available?

Have you spoken with the therapist / director selected above?

Date of Birth (mm/dd/yyyy)

Address

Please provide two ways of contacting you
in the fields below

Preferred Phone

What phone number would you prefer we call for necessary communications and in the event of scheduling questions?

About Your Preferred Phone

my preferred phone is my cell / mobile

my preferred phone is my home

my preferred phone is my work

In the event that we cannot speak with you directly, may we leave a voicemail on your preferred phone?

Yes, please leave a voicemail

No, please do not leave a voicemail

Secondary Phone

If you would like to add a secondary phone number for necessary communications or the event of scheduling questions, please enter the number here:

About Your Secondary Phone

my secondary phone is my cell / mobile

my secondary phone is my home

my secondary phone is my work

May we leave a voicemail?

Yes

Name of Emergency Contact Person

Relationship to Emergency Contact Person

Emergency Contact Phone

Employment & Insurance Information:

Occupation

Level of Education Completed

Employer

Health Insurance Provider

Health Insurance Provider Mailing Address

(this information is often on the back of your insurance card)

Health Insurance Provider Phone Number

Insurance Subscriber Name

(if other than you)

Insurance Subscriber Date of Birth (mm/dd/yyyy)

(if other than you)

Insurance ID Number

Group Number

Employer ID Number

(if listed on insurance card)

Online Health Insurance ID Submission

At this time, you have the option to securely upload your Health Insurance ID with your smartphone or computer.

You may also securely submit just your Health Insurance ID later from the NEW CLIENT portal accessible via our homepage.

Yes, I would like to submit my health insurance ID at this time

No, I will submit my health insurance ID online at a later time

I will bring my health insurance ID to the office for my first appointment

Upload Front of Health Insurance ID

Upload Back of Health Insurance ID

Upload Additional

Personal & Medical Information:

Relationship Status

Do you have children?

If so, what are their ages?

Has a medical doctor treated you in the last six months?

If so, for what medical condition?

Are you still receiving treatment?

Current medical conditions or concerns

Chronic conditions

Has your physician referred you?

Current prescribed medications

Allergies

Name of Primary Care Physician

Phone Number of Primary Care Physician

Name of Psychiatrist

(if applicable)

Mental Health History:

Have you ever been in therapy before?

If so, for how long?

Name(s) of former therapist(s)

(if applicable)

Have you ever been hospitalized for a mental health condition?

If so, where?

If so, when?

Do you use alcohol?

If so, how much and how often?

Do you use tobacco products?

If so, what kind and how often?

Do you use any other drugs?

If so, what types, how often and when?

What are the current stresses influencing your mental health?

What are your related concerns?

Is there a history of depression or anxiety in your family?

If so, what family member(s) and what condition(s)?

If so, did they receive treatment in the past?

Are they still receiving treatment today?

How did you find the Center? Were you referred?

May we email you regarding future events or workshops at the Center?

Employment & Insurance Information:

Personal & Medical Information:

Mental Health History:

Please note: If uploading images, the form may take up to a minute after pressing submit. Your patience is much appreciated.

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