Client Intake Form
Have you ever been seen by anyone at this center before?
Yes
No
Who?
When?
Demographic Information
Please allow 5 - 10 minutes to complete the form.
*
= required
Legal First Name
*
Legal Last Name
*
Address
*
City
*
State
*
- please select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
North Dakota
Nebraska
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip
*
Date of Birth
*
Under 18?
Yes
No
Gender
*
Male
Female
Other
Name of Parent/Legal Guardian
*
Relationship to child
*
Grade in school
*
Contact Information
Best daytime phone #
*
Can we leave a message?
*
Yes
No
Email
*
Would you like appointment reminders to be sent via voice, email, or text?
*
(please specify which):
Voice
Email
Text
Neither
Current job/employer
*
Will you be using insurance?
*
Yes
No
Gross Family Income
-- please select --
$0 - $25,000
$25,001 - $50,000
$50,001 - $75,000
$75,001 - $100,000
over $100,000
Number of people in your family
Is there someone else responsible for the bill?
Insurance Information
Primary Insurance
*
-- please select --
Aetna
Amerigroup
Assurant Health
Beacon (Value Options)
Blue Cross Blue Shield
Cigna
Coventry / MH Net
EAP - (Employee Assistance Program)
Golden Rule
Health Alliance
Health Partners
Humana
Iowa Medicaid
Medicare
Midlands Choice
MultiPlan (PHCS)
Tricare (MHN)
UMR
United Healthcare
United Healthcare of the River Valley
UHC River Valley - Iowa Medicaid
Other
Provider Services Phone #
*
Insurance ID#
*
Group number
Is this an out-of-state plan?
Yes
No
Pre-authorization # and contact person
Are you covered through an MCO?
Yes
No
Amerigroup or UHC of RV?
Amerigroup
UHC of RV
Have you seen any other counselor or psychiatrist in the past 6 months?
Yes
No
What is your PCP's name?
What is your PCP's phone number?
Other Insurance Company Name:
Insured's Name
*
Insured's DOB
*
Insured's Employer
*
Do you have secondary insurance?
*
Yes
No
Secondary Insurance
*
-- please select --
Aetna
Amerigroup
Assurant Health
Beacon (Value Options)
Blue Cross Blue Shield
Cigna
Coventry / MH Net
EAP - (Employee Assistance Program)
Golden Rule
Health Alliance
Health Partners
Humana
Iowa Medicaid
Medicare
Midlands Choice
MultiPlan (PHCS)
Tricare (MHN)
UMR
United Healthcare
United Healthcare of the River Valley
UHC River Valley - Iowa Medicaid
Other
Provider Services Phone #
*
Insurance ID#
*
Group number
Is this an out-of-state plan?
Yes
No
Pre-authorization # and contact person
Are you covered through an MCO?
Yes
No
Amerigroup or UHC of RV?
Amerigroup
UHC of RV
Have you seen any other counselor or psychiatrist in the past 6 months?
Yes
No
What is your PCP's name?
What is your PCP's phone number?
Other Insurance Company Name:
Insured's Name
*
Insured's DOB
*
Insured's Employer
*
What issues are you seeking treatment for?
Abuse/trauma
Aggression/anger
Aging
Anxiety/nerves/worry
Asperger/Autism Spectrum
Attachment disorders/problems
Attention/concentration problems
Behavior problems/acting out
Delusions/thought problems
Dementia/memory problems
Depression
Dissociation
Eating Disorder problems
Emotion management/regulation
Family issues
Grief
Hallucinations
Hyperactivity
Identity concerns
Impulsivity/poor decisions
Intellectual/Learning Disabilities
Learning Disability/school problems
Life Transitions
Mood Swings/mania
Neurological (head injury, seizures, stroke, etc.)
Obsessions/Compulsions
Personality problems
Relationship problems
School problems
Self-injury
Suicidality
Sexual problems
Social problems
Spiritual concerns
Substance use problems
Trauma/PTSD
Unusual behaviors/statements
Work problems/fitness for duty
Other
Unsure
What type of service are you seeking?
Counseling:
Individual counseling
Couples counseling
Premarital counseling
Family counseling
Other Services:
Career Counseling
Parenting skills
Psychological/Neuropsychological Testing
Question goes here...
Psychiatry/Medication
Spiritual direction
Please list any current psychiatric medications
Current prescriber
Are you currently receiving any counseling, or treatment with any provider?
*
Yes
No
With whom and what kind?
Who referred you to our Center?
Doctor/medical professional
Another mental health provider
Friend or family member
Spiritual leader
Internet
Other
Do you have any preferences you would like us to consider when assigning a therapist (such as gender, age, religious or spiritual identity, therapeutic modality, language spoken, etc.)? Are you looking to meet with a specific counselor?
If your schedule is limited, please explain your availability in the box below. Please be aware that we will make every effort to accommodate, but that clinicians may have greater or lesser availability at certain times.
Is there anything else you would like us to know?
Yes, I am interested in learning more about working with a graduate intern therapist.
High quality/low cost counseling services with immediate appointments are offered through the Center's clinical training program, working with advanced graduate interns in their last year of training for mental health counseling.
We look forward to contacting you within three business days