Date of Birth
Emergency Contact Name and Phone Number
Primary Insured Name
Primary Insured Date of Birth
Relationship to Primary Insured
Insurance Group Number
Provider Support Phone Number
* Provider Support Phone Number
How did you hear about Be Well Counseling, LPC?
If yes, when? Please briefly list the reasons and outcomes.
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 group therapy or a support group?
Please list dates and the name of the group.
How were they helpful?
What difficulties did you have, if any?
What else would you like us to know about you?
This form was signed by:
Relationship to patient:
Parent or Guardian's signature: