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, one person will need to be the "identified client." Please use that person's information for all insurance and billing questions.
Full legal name (Or names, if seeking therapy as a couple) *
Preferred name(s) (if different)
Today's date *
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What kind of counseling are you seeking? *
Name of person completing intake, if different than person seeking treatment:
How were you referred to Firefly Counseling? *
Have you ever been to therapy before? At what age(s) and for how long?
Home address (include #, street, city, and zip code): *
Mailing address (if different than above):
Email address: *
Home/ cell phone numbers: *
Preferred contact method: *
Date of birth: *
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Age: *
Gender (include preferred pronouns): *
Highest level of education (or current grade if in school): *
Relationship Status: *
Insurance Provider (write "out of pocket" if you wish to pay without using insurance): *
Insurance: Policy holder name, date of birth, address, phone number *
Insurance: ID number, group number (if applicable), and co-pay *
Employer (or school): *
Job title:
Emergency contact (include name, number, and relationship to you): *
Reason for seeking counseling at this time: *
Current issues (check all that apply): *
Required
What's going on in this present moment that contributes to the current issues you are facing? Life transitions? Struggles? Barriers/ obstacles to your current hopes and needs? *
Any past issues or barriers/ obstacles that you'd like to share?
Tell me about your supports! What things do you do to take care of yourself when you're experiencing something difficult? Who do you reach out to? Are they local or out of state?
What are you good at? What brings you joy? What do you like about yourself, and about your life? *
Do you have a family history of mental health concerns? If so, what specifically? (If you don't know, that is a completely acceptable answer) *
Do you walk to talk about spirituality or faith as a part of your therapy? [NOTE: I do NOT prescribe beliefs of ANY sort to clients; rather, I DO support clients to find what brings them light and joy and faith (of any sort, in a non-denominational manner)] *
Do you want to talk about sexual intimacy as a part of your therapy? *
Primary care provider's name, practice, and location: *
Do you give Katie Hoar, LCSW permission to contact your primary care physician listed above? *
Please list any significant medical issues (include any hospitalizations): *
Are you currently taking any psychotropic medications (medications for mental health concerns)? *
If yes, please list (or write "prefer not to answer here"):
Do you use alcohol or other recreational drugs? If yes, what? How much? How often? *
What time of day are you available for appointments? *
What day(s) of the week work best for you? (note: no Friday appointments available) *
Required
Is there anything else you would like Katie to know?
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