Intake Form
Please answer all questions that pertain to you. You may choose to have a copy of your completed form sent to your email by checking the toggle at the end. You may also request a copy of the completed form be shared with you using more secure means than email.

Some questions will require an answer, those with red stars. Please enter "none" or "not applicable, n/a" if you have nothing to input.

This completed form will become part of your record. Some of these questions involve very private information. Google Forms as employed by this practice is more secure than email, and in many ways, more secure than voice communication (which must be noted for input into the computer system). The information is stored directly into the practice's Gsuite storage, which is protected by HIPAA-compliant security.

This practice uses one intake form for all clients, regardless of whether they pay by insurance or fee-for-service. Many of the questions are required by insurance companies--which all have different requirements--and asking them here is designed to simplify the intake interview for those companies that require one. You do not have to answer any question you don't want to in order to receive services; the counselor will follow up with you if you have not answered a question and she believes it needs to be pursued further.

Completion of this form does not establish you as a client or patient: that occurs with the completion of the Informed Consent Agreement and the first appointment.

This practice does not provide emergency services or crisis consultation to non-clients. If you believe you or or another are in danger, please contact emergency services in your area. These might include: police, sheriff, hospital emergency department, crisis mental health services provided by your local municipality, your primary care physician or practice. If you are having thoughts of self-harm, additional resources may be found at suicidepreventionlifeline.org, or by calling the suicide prevention hotline at 1-800-273-8255 in the US. Crisis text services may be accessed by messaging 741741. In Iowa, additional support may be accessed through the Foundations 2 hotline at 1-800-332-4224.

Thank you for your patience, and we're looking forward to supporting you in achieving your goals.
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Covid-19 Mask Policy
Anne Lindyberg, Licensed Counselor (LMHC Iowa, and LCPC under temporary permit exp 12/31/21 in Illinois) and the practice Connection Is, LLC requires adherence to certain policies around the Covid-19 pandemic and viral risks currently present and possible to arise in the future.
KN95 or N95 masks are required to be worn by all in the waiting room and offices at all times. One new KN95 mask will be provided for free for each client (they are surprisingly comfortable). Additional masks may be purchased for $1 each. The client's KN95 mask may be kept securely and confidentially at the office by the counselor, if it is more convenient for client. Please choose one of the following. You may leave a comment under "other." *
Required
Name of identified client (as given on insurance card) *
Is the person filling this form out the client? *
Required
Client's nickname or preferred name, preferred pronouns
If identified client is a minor or dependent adult, please give name, role and contact information for parent, legal guardian or principal advocate:
If client is a minor, or dependent adult requiring assistance to arrange and attend services, parent or guardian will need to bring, scan and email or fax an official copy of birth certificate, custody papers (if there is a custody agreement) or guardianship papers to first appointment. Without these, the appointment will not proceed. It must be an official copy (bear evidence of a seal). *
Birthday of identified client. This is required of all clients and is kept confidential. All information entered into this form is stored directly in Connection Is, LLC's HIPAA-compliant Google Cloud Storage account. *
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Gender of identified client as listed on insurance card, or preferred gender if insurance is not being used. Please note your preference under "other" if a different designation from the insurance company's is preferred. *
Required
Social Security Number of Primary Client. This is required for clients using insurance to pay for services, planning to in the future, or private pay. *
Mailing address (used by insurance company to communicate with client or guardian). This is required of all clients. Please include city and zip code. *
Street address where primary client resides, if different from mailing address. This is required of all clients who do not reside at their mailing address. Please include city and zip code.
Best telephone number *
I would like to receive texts at this number
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I can receive a detailed message at the number given. If yes, describe any limits below.
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