Northlight Counseling New Client Questionnaire

Welcome, this is your first step to obtain services at Northlight!

Instructions: 

Please fill out this form to the best of your ability with as much information as possible. You will need to have your insurance information ready to complete this form.

After reviewing this form, a Client Care team member will determine if we can accommodate your needs (based on your preferences, availability, and insurance eligibility). You will be invited to schedule an intake screening with a intake coordinator, to share more about your specific therapy needs, before you get scheduled with one of our therapists.

Therapist Availability changes weekly. Placement with a therapist is not guaranteed. Northlight therapists provide recurring appointments: once scheduled, you will have the same appointment time and day weekly or bi-weekly. We cannot accommodate schedules that change from week to week.

At this time, we have limited availability for individuals with MEDICARE. Not all our providers are eligible Medicare Providers.

Confidentiality is Important to us! This Form is Secure, meets HIPAA requirements and is treated with care!

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Email *
Northlight provides Counseling and Psychotherapy. Unfortunately, we can not provide the services listed below. Our providers work closely with other healthcare professionals to help meet the needs of our clients.

  •  Medication management. 

  • Treatment focused primarily on Addiction needs

  •  Psychological evaluation with a Psychologist/ ADHD or Autism Assessments

  •  ESA Letters, Disability/Social security evaluations, Custody evaluations 

  •  Mandated treatment

  •  Letters for Gender Transition care (letters for surgery and hormones). While we offer psychotherapy and counseling to Transgender clients to assist with many mental health needs, Northlight Counseling currently does not have a specialist who is a trained evaluator for Gender transition Gender-reassignment care. Therapists are bound by an ethical code that requires them to work within the scope of their practice and training. Northlight Counseling therapists work closely with specialists who are trained evaluators and offer Letters for hormone treatment and Gender reassignment surgery.

  •  DHS or court custody litigations

  •  Crisis/ immediate Services

  • Inpatient Care

Tell us about you!
Your (Legal) Name 
(client information if you are completing this form for a Minor)
 *
Your Preferred Name
Information regarding minors and therapy. This form may be completed by Parents, guardians or caretakers who have legal decision making power, or by an individual between 14 and 17. Minors 14-17 years old may request therapy without parental consent. If you are an adult completing this on behalf of a minor between 14 and 17, please beware that the Minor will also have to consent to therapy.
Is the client a Minor?  *
Parent/Guardian name (If client is a Minor)
Preferred Pronouns
Date of Birth (month/day/year)
 *
MM
/
DD
/
YYYY
Address  (Street, City, State, Zip)
 *
Phone number
 *
Can we contact you by phone?
 *
Can we contact you by Text message?
 *
Can we leave a voicemail?
 *
Can we contact you by email?
 *
Preferred communication (check as many as you want) *
Required
Emergency contact: Name, Relation, Phone number, Email. *

Sex (Required for insurance billing)

 *
Gender
Do you have any accessibility needs?
Do you require a translator? If so, please specify the language.
Identity,  Ethnicity and Race
Is there something specific about your Identity you would like us to know? (Gender identity, Sexual Orientation, Ethnic or Cultural identity, Religious or Faith affiliation)
Are you of Hispanic, Latino or Spanish origin?
 *
How would you best describe yourself?
 *
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