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Camas Professional Counseling Screening Form
Please complete this screening form. We do our best to get back to you within 48-72 business hours of your submission. Our wait list is currently at least a month long, depending on your funding source. Thanks in advance for your patience while we customize your care and get you in as soon as we can.
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Email
*
Your email
Name
*
Your answer
Name of client and relation to you (if other than self)
Your answer
Age of Client
*
Your answer
Date of Birth of Client
*
MM
/
DD
/
YYYY
Physical Address of Client (Please include City and State)
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Your answer
Please indicate your insurance situation. All of our clinicians, case managers, and peer support take insurance, but the type of insurance does vary between our staff. Select all that apply. If your insurance is not listed please indicate what type of insurance you do have under "other."
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Medicare
Medicaid
Blue Cross of Idaho
Regence
Self Pay
Other:
Required
Insurance ID #
*
Your answer
Insurance Group # (if no group number, put NA)
*
Your answer
Phone Number
*
Your answer
Preferred Method of Contact
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Phone
Email
Other:
How did you hear about us?
Your answer
What are you seeking support with? Please check all that reflect a primary therapy need for support. Under "other" please indicate anything else that would be helpful to know about you in considering a therapist match.
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Anxiety
Depression
Stress Management
Significant Life Changes/Transitions
Grief/Loss/Bereavement
Obsessive-Compulsive Symptoms
Relationship Issues
Domestic Violence - Past
Domestic Violence - Current
Childhood Sexual Abuse
Childhood Physical Abuse
Childhood Verbal Abuse
Childhood Trauma
Acute or Chronic Trauma
Post Traumatic Stress Disorder
Secondary Trauma
Caregiver Stress
School Issues
Panic Attacks
Identity Issues
Career Counseling
Personality Disorders
Criminal/Legal Issues
Chronic/Critical Illness
Self-Harming Behaviors
Need a Diagnostic Evaluation to Determine Diagnosis
Other:
Required
Preferred Availability for Appointments (best days and times)
*
Your answer
Would you be willing to see an intern, if an intern is available?
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Yes
No
Maybe
Would you be open to online (Telehealth) Counseling?
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Yes
No
Maybe
Anything else we should know?
Your answer
By checking the box below you understand due to circumstances such as limited availability, insurance, and or the reasons in which you are seeking services for, that this form is not a guarantee of services.
*
I agree to the above statment
Required
Please acknowledge that you understand it could take up to 48 business hours for us to see your form and process it. Our administrative staff is in the office Monday through Thursday. Please wait 2-3 days before following up.
*
I agree to the above statement
Required
Required Consent
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By submitting this form, you consent to your information being transmitted through the internet to our records. Like any other internet-based system, we do our best to protect your information.
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Send me a copy of my responses.
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