Get Started with Services

Get Started with Services

Mental Health Client Initial Referral and Paperwork
Electronic Communication

Please check the box below to consent for Sunbeam to follow up with regarding this referral and scheduling via email.
I understand that by completing this form I am consenting for Sunbeam to communicate with me via the email listed below regarding my referral and possible future scheduling of services. *

I consent
Full Name of Client *

First Name Last Name
Name of Person Completing Form *

First Name Last Name
Relationship to Client *
Phone Number *
Please enter a valid phone number.
May we leave a message at the preferred number? *

Yes No
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security Number *
Date of Birth *
Race (select all that apply) *

American Indian/Alaskan Asian Black/African American Hawaiian/Pacific Islander Hispanic/Latino White/Caucasian
Ethnicity *

Hispanic/Latino Not Hispanic/Latino
Sex (For Billing Purposes Only) *
Marital Status *
Gender
Pronouns

He/Him She/Her They/Them Other
Emergency Contact *

First Name Last Name
Relationship to Client *
Phone Number of Emergency Contact *
Please enter a valid phone number.
Is Client under age 18? *

Yes No
If under 18, Parent or Guardian Name *

First Name Last Name
If under 18, is there a custody agreement in place? *

Yes No
If under 18, is there currently DHS Custody? *

Yes No
If Yes, DHS Worker Name *

First Name Last Name
DHS Worker Email *
example@example.com
DHS Work Phone Number *
Please enter a valid phone number.
What type of mental health service are you looking for? *

Individual (Just me/Just client) Couples Family
How can we help? *
Tell us what you're looking for in your counseling experience and specifically in the therapist who works with you.
Mental Health

Within the last 90 days (3 months) have you had a significant period in which you have:
Experienced serious depression (felt sadness, hopelessness, loss of interest, change of appetite or sleep pattern, difficulty going about your daily activities?) *

Yes No
Experienced hallucinations (heard or seen things others don't hear or see)? *

Yes No
Experienced thoughts of harming yourself? *

Yes No
Attempted suicide? *

Yes No
Been prescribed medication for any psychological or emotional problem? *

Yes No
Domestic Violence
Have you ever been afraid of your partner and/or a family member? *

Yes No
Have you ever been hit, slapped, kicked, emotionally or sexually hurt, or threatened by someone? *

Yes No
If you answered yes to either of the above questions, is the person who hurt or threatened you still a part of your life? *

Yes No
Have you ever used gestures, threats, and/or thrown or broken objects as a means to intimidate your partner or a family member? *

Yes No
Have you ever pushed, restrained, hit, slapped, or used any other physical means to harm your partner or a family member? *

Yes No
Trauma
Have you experienced a traumatic event and since had repeated nightmares/dreams and/or anxiety which interferes with you leading a normal life? *

Yes No
Substance Use

During the past year, have you:
Drank alcohol and/or used drugs more than you intended? *

Yes No
Tried to stop drinking alcohol and/or using other drugs, but couldn't? *

Yes No
Experienced problems caused by drinking alcohol and/or using drugs, and you kept using? *

Yes No
Drank alcohol and/or used other drugs to alter the way you feel? *

Yes No
Been preoccupied with drinking alcohol and/or using other drugs? *

Yes No
Needed to drink more alcohol and/or use more drugs to get the same effect you used to get with less? *

Yes No
Adverse Childhood Experience (ACE) Questionnaire

When growing up, during the first 18 years of life:
Did a parent or other adult in the household often swear at you, insult you, put you down, humiliate you or act in a way that made you afraid that you might be physically hurt? *

Yes No
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? *

Yes No
Did an adult or person at least five years older than you ever touch or fondle you or have you touch their body in a sexual way; or try to actually have oral, anal, or vaginal sex with you? *

Yes No
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? *

Yes No
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? *

Yes No
Were your parents ever separated or divorced? *

Yes No
Was your mother or step mother often pushed, grabbed, slapped, or had something thrown at her; or sometimes or often kicked, bitten, hit with a fist, or with something hard; or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? *

Yes No
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? *

Yes No
Was a household member depressed or mentally ill or did a household member attempt suicide? *

Yes No
Did a household member go to prison? *

Yes No
Please add up all of your "Yes" responses and put the total here: *
Check all that apply *

I (or my child) received services in the past at Sunbeam I am looking for medication services I was referred by another agency I have an open case with DHS
How did you hear about us? *

Boys and Girls Club Bench Ad Billboard Bus Ad Friend/Family Member Internet Newspaper Palomar Radio Social Media Sunbeam Early Childhood Services Sunbeam Foster Care Sunbeam Senior Engagement Program TV Work
Annual Income *
Number of Individuals Living in Household *
How will you be paying for services? *
Insurance Company *
Insurance Member ID Number *
Insurance Group Number
Name of Insured (if different from self)

First Name Last Name
Date of Birth of Insured (if different from self)

Month Day Year
Date
Social Security Number of Insured (if different from self)
If using an EAP or Mental Health Services benefit, what employer provides your benefit? If you do not see your employer below, please contact your HR to find out who your EAP services are through. *
Account Responsible Name (if self, leave blank; if parent/legal guardian, please fill out below)

First Name Last Name
Account Responsible Date of Birth

Month Day Year
Date
Account Responsible Phone
Please enter a valid phone number.
Account Responsible Email
example@example.com
Account Responsible Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Availability for Appointments (select all that apply) *

Monday Tuesday Wednesday Thursday Friday Mornings (8am-Noon) Afternoons (Noon-4pm) Evenings (4pm-8pm)
By submitting this document:

I understand that completion of this document is for the purpose of determining client suitability for services and does not guarantee services provided by Sunbeam and that referral resources will be provided for those who do not qualify.
Should be Empty:

Get Started with Services

Electronic Communication

Mental Health

Domestic Violence

Trauma

Substance Use

Adverse Childhood Experience (ACE) Questionnaire

By submitting this document: