Who is this request for services for?
*
Adult (21 years or older)
Child (under 21 years of age)
Please list full name of Person completing this form
Please list the full name of the parent or guardian who is responsible for authorizing treatment
*
Please list relationship to client
Client Name
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First Name
Last Name
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Phone Number
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-
Area Code
Phone Number
Date of Birth
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-
Month
-
Day
Year
Date of Birth
Sex
*
Female
Male
Is the client Active Duty Military, a reservist, or a First Responder?
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Yes
No
Please List the Name of Your Insurance Company
Please Provide Your Insurance ID number
Please Provide Your Insurance Group Number
Does the client have current suicide ideations or thoughts? * If client marks yes, call the Suicide and Crisis Lifeline (988) or go to your nearest Emergency Room.
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Yes
No
Does the client have any of the following concerns? (Check all that apply)
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Anxious/worried
Depressed/unhappy
Eating disorder/body image concerns
Hyperactive/inattentive
Shy/withdrawn
Low self-esteem
Aggressive behaviors
Stealing
Destruction of property
Anger
Dishonesty
None
Does the client have any of the following concerns with school? (Check all that apply):
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Homework not turned in/not completed
Low test/assignment grades
Poor classroom performance
Sleeping in class/always tired
Sudden change in grades
Frequently tardy or absent
New student
Personal hygiene
None
Does the client have any of the following concerns with relationships? (Check all that apply):
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Bullying
Difficulty making friends
Poor social skills
Problems w/friends
Boy/girlfriend issues
None
Does the client have any of the following concerns at home? (Check all that apply):
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Fighting w/family members
Illness/death in the family
Parents divorced/separated
Suspected abuse
Parent Request
None
List any other information that you would like us to be aware of regarding the client and/or yourself?
How did you hear about us ?
*
Instagram
Facebook
Email
Google Ads
Television
Radio
Other
If other , Please list here
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