New Client Information Form
Please provide us with the following information to help us determine if we can meet your mental health needs. Answers will be kept confidential, except in cases of suspected child/elder abuse, imminent risk of harm to self/others, and in compliance with court orders.
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Email *
Legal Name *
Preferred Name (if different)
Address, including City, State, Zip *
Phone number *
Can we leave a message, text, or email you for scheduling, billing, and other important items?
Date of Birth *
Gender  *
Primary Insurance Company  

(For OHP, please specify which county you're covered in and which Care Coordination Organization it is managed by. 
Put "none" if you are uninsured.)
 *
Primary Insurance Member ID# *
Secondary Insurance Company & Member ID 
(Put none, if not applicable)
Please include any other plans you are covered under, including a parent's or spouse's.
 *
Do you have MEDICARE coverage? 
(Please note, this is different from Medicaid. 
Medicare is primarily for those 65+ or on disability. We do NOT accept Medicare.)
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What are you wanting to work on in counseling? *
Have you ever been diagnosed with a mental health disorder? If so, which one(s)? *
Are you currently working with another therapist? (If YES, please describe.) *

Have you had any thoughts about harming yourself or others in the last 6 months? If yes, please describe.

 *
Do you prefer in-person or online sessions? *
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