Counseling Services Request Form

Counseling Services Request Form

Thoughtful Wellness, LLC
Date

Month Day Year
Date
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Gender
Primary Care Physician

First Name Last Name
Please list the problem(s) which you are seeking help?
Current Symptoms

Depressed mood Racing thoughts Excessive worry Unable to enjoy activities Impulsivity Anxiety attacks Sleep pattern disturbance Increase risky behavior Avoidance Loss of interest Increased libido Hallucinations Concentration/forgetfulness Decrease need for sleep Suspiciousness Change in appetite Excessive energy Excessive guilt Increased irritability Fatigue Crying spells Decreased libido
Have you ever had feelings or thoughts that you didn't want to live?

Yes No
Do you currently feel that you don't want to live?

Yes No
How often do you have these thoughts?
When was the last time you had thoughts of dying?

On a scale of 1 to 10, (ten being strongest) how strong is your desire to kill yourself currently?

	1	2	3	4	5	6	7	8	9	10

1 is Weak, 10 is Strong

	Yes	No
Do you feel hopeless and/or worthless?
Have you ever tried to kill or harm yourself before?
Is there anything that would stop you from killing yourself?

Psychiatric History:
Outpatient treatment

Yes No
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization

Yes No
If yes, Please describe when, by whom, and nature of treatment
Are you currently:

Working Student Unemployed Disabled Retired
Emergency Contact

First Name Last Name
Phone Number

Area Code Phone Number
Signature

Clear
Guardian Signature (if under age 18)

Clear
Please chose your insurance plan(s) *

Aetna Allied Benefit System Benefit Management LLC Capital Blue Cross CHIP Gateway Medicare Assured Highmark Humana Mazzitti & Sullivan EAP Medical Assistance- Berks County Medical Assistance- York/Adams County Medical Assistance- Lancaster County Medicare Meritain Optum Health Behavioral Solutions (previously United Behavioral Health) Quest Teamsters Trustmark United Healthcare UMR UPMC Victim Compensation Fund Wellspan EAP
Should be Empty:

Psychiatric History: