Counseling Services Request Form

Counseling Services Request Form

Thoughtful Wellness, LLC
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Primary Care Physician

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

Depressed moodRacing thoughtsExcessive worryUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceIncrease risky behaviorAvoidanceLoss of interestIncreased libidoHallucinationsConcentration/forgetfulnessDecrease need for sleepSuspiciousnessChange in appetiteExcessive energyExcessive guiltIncreased irritabilityFatigueCrying spellsDecreased libido
Have you ever had feelings or thoughts that you didn't want to live?

YesNo
Do you currently feel that you don't want to live?

YesNo
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

YesNo
If yes, Please describe when, by whom, and nature of treatment
Psychiatric Hospitalization

YesNo
If yes, Please describe when, by whom, and nature of treatment
Are you currently:

WorkingStudentUnemployedDisabledRetired
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Signature

Clear
Guardian Signature (if under age 18)

Clear
Please chose your insurance plan(s)*

AetnaAllied Benefit SystemBenefit Management LLCCapital Blue CrossCHIPGateway Medicare AssuredHighmarkHumanaMazzitti & Sullivan EAPMedical Assistance- Berks CountyMedical Assistance- York/Adams CountyMedical Assistance- Lancaster CountyMedicareMeritainOptum Health Behavioral Solutions (previously United Behavioral Health)QuestTeamstersTrustmarkUnited HealthcareUMRUPMCVictim Compensation FundWellspan EAP
Should be Empty:

Psychiatric History: