Name
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First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
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Email Address
*
Date of Birth
*
Emergency Contact Name and Phone Number
*
Insurance Company Name
*
Insurance ID (include any letters)
*
Primary Insured Name
*
Primary Insured Date of Birth
*
Relationship to Primary Insured
*
Insurance Group Number
*
Provider Support Phone Number
*
(###)
###
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How did you hear about Be Well Counseling, LPC?
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Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)
If yes, when? Please briefly list the reasons and outcomes.
Do you currently have a therapist you work with?
Are you currently taking any medication for mental health issues?
If yes, please explain:
Are you in recovery from substance or alcohol abuse? If so, how long have you been sober? Please provide a brief description of the treatment and support you receive for maintaining sobriety?
Do you have a history of eating disorders or disordered eating? If so, please provide information on the support and treatment you are/have received.
Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues.
What previous experience have you had, if any, with therapy, group therapy, or a support group?
What would you like to work on in therapy?
What else would you like us to know about you?
This form was signed by:
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Relationship to patient:
*
Parent or Guardian's signature:
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By signing this form you are acknoledging that you agree with Be Well Counseling's policies, understand informed consent of treatment, and agree to fee schedule outlined in financial policy, and discussed in initial intake session of therapy. You are responsible for any fees that your insurance does not cover.
