Family/Couples Intake Questionnaire

Family/Couples Intake Questionnaire

Welcome to Overcomers Counseling! Thank you for taking a few minutes to fill out this form. The information you provide is confidential and will be helpful for you and your counselor when you meet for the first time. If you have any questions, just ask!
Your Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Date of Birth*

MonthDayYear
Gender*
Emergency contact person (name, relationship, phone, address) *

Medicaid Members (only)
Are you in need of transportation?

YesNo
If Yes (above) please follow these steps:

Most Health First Colorado members can get a ride using IntelliRide. If you live in Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, or Weld County: call IntelliRide at 1-855-489-4999 (toll free) (State Relay 711) or go to Gointelliride.com/Colorado to get a ride, including air, train, or out-of-state travel. Or, request mileage reimbursement if you use a personal vehicle.

If you live in any other Colorado county: Contact a local NEMT provider in your community. Go to hcpf.colorado.gov/nemtlist to find a local NEMT provider. If you need personal vehicle mileage reimbursement, air, train or out-of-state travel, call IntelliRide at 1-855-489-4999 (toll free) (State Relay 711) or go to Gointelliride.com/Colorado.

Family Members*

Marital Status (Check all that apply)*

SingleDatingCommitted RelationshipEngagedMarriedSeparatedDivorcedWidowed
Please describe current living arrangements*

How can we help?
What are the obstacles your family is facing? What are the struggles?*
What are the goals for your family? What do you want to be accomplished or changed as a result of therapy?*

Please write specific notes about each family member, if desired:*

HIPAA Compliant Authorization For Exchange Of Health Information
I authorize my therapist at Overcomers Counseling to exchange my information with my partner/family member(s) listed above.*

Yes
Should be Empty:

Insurance Information