Pre Screen Intake Form
Thank you for choosing Revive Wellness Group! Our practice specializes in Womens Mental Wellness. Please answer each question honestly and to the best of your knowledge.You must be18 years old or older to complete this form. If you are not over 18 years old, do not continue.
Email *
Are you completing this form for yourself or someone else? (If you are not over 18 years old, do not continue. No exceptions.) *
If you're completing this form for someone else because you're the parent, legal guardian or authorized representative, what is your name?
If you're completing this form for someone else, what is your relationship to the person you're referring?
Clear selection
What services are you interested in? We do not offer therapy for children and families at this time. *
Required
How would you prefer to have appointments? *
First Name (person who will receive services) *
Last Name (person who will receive services) *
Preferred Name (if different from legal name)
Date of Birth (person who will receive services) *
MM
/
DD
/
YYYY
Age (person who will receive services) *
Pronouns (e.g., she/her, he/him, they/them)
Preferred Phone Number *
Preferred Email Address *
BRIEFLY tell us why you are  seeking mental health treatment? Be brief, but specific. *
BRIEFLY tell us what do you are hoping to gain from treatment? Be brief, but specific. *
How long has this been a concern or area of focus for you? *
Describe any recent changes to make this concern or area of focus difficult? *
Have you participated in therapy treatment in the past? *
How long ago did you  participate in therapy treatment?
How motivated are you to participate in therapy? *
Do you understand that Revive Wellness Group  is  only accepting Aetna, Cigna, and United Healthcare insurance benefits at this time? If you do not have any of the accepted insurances you will be considered self-pay (Rate is $160 for 55 min session)  should you choose to move forward in seeking treatment at Revive Wellness Group. If you are not in agreement, please do not submit.  We do not accept Medicare or Medicaid Plans. *
How did you hear about us? *
Please read carefully. The word consent means to give permission or be in agreement. If any are left blank, your appointment request will be denied. *
Required
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of therevivewellnessgroup.com.