Counseling Screening Form

**Please complete to the best of your ability . If you are uncomfortable or unable to do so, your counselor will assist you during your intake.

Date Form Completed

Date

Were you referred by another White Bird Department or another agency?

If Other Agency, which one?:

Name *

Previous Names Used

Address including City, State, and Zip

Phone

Is it ok to identify ourselves if we call you?

Yes No

E-mail

example@example.com

Is it ok to contact you through e-mail?

Yes No

Date of Birth *

Date

Preferred Language *

Preferred Language (if Other selected):

Tribal Affiliation, if applicable

Race *

Ethnicity

Ethnicity *

Living Situation *

Gender Identity *

Sexual Orientation

Sexual Orientation (if Other selected):

Pronouns Used

Birth Sex

Current Gender

Highest Grade of School Completed

Occupation

Gross household monthly income

Number of people in household, including dependants *

Source of Income *

Source of Income (if Other selected):

Do you have OHP (Medicaid): *

Yes No Unsure

Name on OHP Card

Member ID number on OHP card

If you do not have OHP, how do you plan on paying for services *

I would like someone to reach out to me and help me sign up for OHP I'm planing on paying out of pocket using your sliding fee scale I'm interested in seeing if I qualify for any grants Does not apply, I have OHP

Do you have a primary care physician:

Yes No

If you have a physician, please include their information

Have you ever used tobacco or nicotine products? *

Yes No

Have you ever been in the military? *

Yes No

What branch?

Type of discharge

Briefly describe why you are seeking counseling services at this time *

Are you more interested in:

Brief counseling/therapy (8 sessions or less) Longer term counseling/therapy (9 sessions or more) Unsure

Please indicate days and hours you're available for counseling services: *

Please note that if you are not comfortable answering these questions now, your therapist can offer support at time of intake.

Adverse Childhood Experience (ACE) Questionnaire:

Yes

No

Did a parent or other adult in the household often...swear at you, insult you, put you down, or humiliate you?
or
Act in a way that made you afraid that you might be physically hurt?

Did a parent or other adult in the household often...push, grab, slap, or throw something at you?
or
Ever hit you so hard that you had marks or were injured?

Did an adult or person at least 5 years older than you ever...touch or fondle you or have you touch their body in a sexual way?
or
Try to or actually have oral, anal, or vaginal sex with you?

Did you often feel that...no one in your family loved you or thought you were important or special?
or
Your family didn't look out for each other, feel close to each other, or support each other?

Did you often feel that...you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?
or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Were your parents ever separated or divorced?

Was your mother or stepmother...often pushed, grabbed, slapped, or had something thrown at her?
or
Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
or
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Was a household member depressed or mentally ill or did a household member attempt suicide?

Did a household member go to prison?