New Client Information Form
Please complete the form below. If you have questions, feel free to reach out via email to katie@fireflycounselingvt.com. If you are filling out a form for a couple or family, please answer all long-form questions for each person who will be included in session.
Full legal name *
Your answer
Preferred name (if different)
Your answer
Today's date *
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DD
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What kind of counseling are you seeking? *
Name of person completing intake (if different than above) and relationship to person seeking counseling:
Your answer
How were you referred to Firefly Counseling? *
Have you ever been to therapy before? At what age(s) and for how long?
Your answer
Home address (include #, street, city, and zip code): *
Your answer
Mailing address (if different than above):
Your answer
Email address: *
Your answer
Home/ cell phone numbers: *
Your answer
Preferred contact method: *
Date of birth: *
MM
/
DD
/
YYYY
Age: *
Your answer
Gender (include preferred pronouns): *
Your answer
Highest level of education (or current grade if in school): *
Your answer
Relationship Status: *
Insurance Provider: *
Your answer
Insurance: Policy holder name, date of birth, address, phone number *
Your answer
Insurance: ID number, group number (if applicable), and co-pay *
Your answer
Employer (or school): *
Your answer
Job title:
Your answer
Emergency contact (include name, number, and relationship to you): *
Your answer
Reason for seeking counseling at this time: *
Your answer
Current issues (check all that apply): *
Required
List any current stressors (significant factors that contribute to that which you checked above): *
Your answer
List your strengths, interests, and experiences that contribute to your overall wellbeing: *
Your answer
Primary care provider's name, practice, and location: *
Your answer
Do you give Katie Hoar, LCSW permission to contact your primary care physician listed above? *
Please list any significant medical issues (include any hospitalizations): *
Your answer
Are you currently taking any psychotropic medications (medications for mental health concerns)? *
If yes, please list (or write "prefer not to answer here"):
Your answer
Do you use alcohol or other recreational drugs? If yes, what? How much? How often? *
Your answer
What time of day are you available for appointments?
What day(s) of the week work best for you? (note: no Friday appointments available)
Is there anything else you would like Katie to know?
Your answer
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