New Therapy Client Questionnaire
These questions will help our intake coordinator match the best therapist we have for your individual needs. The best possible client-therapist fit is very important to us and something that we take very seriously. We also use your answers to create a chart in our electronic health system should you decide to move forward with one of our therapists. After you fill out this questionnaire, we will contact you within 24-48 business hours. Please note that we accept private pay, Medicare, Tricare, and Blue Shield Magellan insurance at this time. There is a space below if you would like us to check your out of network (OON) benefits. If you have any questions, feel free to call or text us at (925) 885-6070 or email us at info@aspireneuropsych.com
Sign in to Google to save your progress. Learn more
Email *
What is your first and last name? *
What is your phone number? *
INSURANCE
Please complete this section if you have Medicare, Tricare, Blue Shield Magellan health insurance OR if you would like us to check your out of network benefits.
Insurance carrier name
Member ID #
What is your date of birth? (we use this information to check your benefits)
MM
/
DD
/
YYYY
Name and date of birth of primary subscriber
THERAPY NEEDS/GOALS
What are you currently struggling with? *
What are your goal(s) for therapy? *
Have you ever experienced thoughts of wanting to hurt/kill yourself or someone else? *
Have you ever had any suicide or homicide attempts? *
PREVIOUS DIAGNOSES/TREATMENT
Have you been previously diagnosed with a mental health condition by a professional? If yes, please list all previous diagnoses *
Is this your first time in therapy? *
Please let us know if you know which therapist that you would like to work with. Therapist bios can be found on our website at www.aspireneuropsych.com
Is there anything else that you would like us to know?
Please note that our therapists are not crisis counselors. We encourage all clients to call 911 or go to their nearest emergency room if you are having a mental health crisis. Thank you for your time, we will be in touch shortly.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Aspire Neuropsychological Services, Inc.. Report Abuse