Counseling Services Request Form
Thoughtful Wellness, LLC
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Gender
Please Select
Male
Female
Trans male
Trans female
Genderqueer
Non-binary
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
Other
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
Weak
Strong
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
Submit
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