Confidential Intake Form for Village Counseling Services
* Required
Last Name:
*
Your answer
First Name:
*
Your answer
If you are not the client, but referring a client to us, please leave your name, address, phone and email address:
*
Please fill out the rest of this form as if you were the client.
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Social Security Number:
*
Your answer
Phone # where you can be reached between the hours of 9 am and 1 pm M-F
*
Your answer
Additional phone #s?
Your answer
What is your email address?
*
Your answer
What is your home address?
*
Your answer
Who referred you, or where did you find out about VCS?
*
(If referred, please include name, address, email and phone number of referrer)
Your answer
Have you been a client of VCS's in the past?
*
Your answer
What is the reason you are seeking treatment now?
*
(For instance, depression, anxiety, relationship issue, etc.)
Your answer
Are you currently or have you recently been in an Intensive Outpatient or Inpatient Program?
*
If so, where and what was/is your discharge date?
Your answer
If known, please indicate the type of treatment you are seeking?
Individual Psychotherapy
Family Psychotherapy
Psychiatric Evaluation/Medication Management
Psychological Testing & Diagnostic Evaluation
Dialectical Behavior Therapy Program (DBT)
Mindfulness-Based Cognitive Therapy (MBCT)
Eye Movement Desensitization Reprocessing (EMDR)
Are you currently or have you recently been suicidal? If yes, when?
*
Your answer
Are you currently on any medications for your mental health?
*
Yes
No
Who prescribes your current mental health medication?
Please provide the name telephone number of the doctor.
Your answer
If you will be seeing our Psychiatrist for medication management please give us the name and telephone number of your pharmacy?
Your answer
Do you prefer a female or male therapist?
Female
Male
No Preference
Please list your availability (for instance, "during the day," or "evening only, " or "any day but Wednesday"
Your answer
Will you be using an Employee Assistance Program (EAP) Benefit from your Employer?
If so, please provide the EAP Name, Contact person and contact phone number.
Your answer
What is the name of your primary Insurance Company?
*
(For example, Blue Cross, or Medicare)
Your answer
What is the insurance type?
(For example, POS, PPO, HMO, etc.)
Your answer
Name of the Subscriber (if not yourself):
Your answer
Social Security # of Subscriber (if not yourself):
Your answer
Subscriber Date of Birth (if not yourself):
MM
/
DD
/
YYYY
Relationship of Subscriber to the Client:
*
Self
Partner/Spouse
Mother
Father
Insurance ID number:
*
Your answer
Insurance Group number:
*
Your answer
Provider phone number, or phone for Mental Health or Behavioral health benefits:
*
Your answer
Do you have Secondary Insurance?
*
If you do, please fill out the Secondary Health Insurance questions that follow. If not, please click "Submit" and we will contact you with appointment times. Thank you!
Yes
No
Secondary Health Insurance Company Name:
Your answer
What is the Secondary insurance type?
(For instance, POS, PPO, HMO, etc.)
Your answer
Name of the Secondary insurance Subscriber (if not yourself):
Your answer
Subscriber relationship (Secondary Insurance):
Self
Partner/Spouse
Mother
Father
Subscriber Date of Birth for Secondary (if not yourself):
MM
/
DD
/
YYYY
Secondary Insurance ID number:
Your answer
Secondary Insurance group number:
Your answer
Secondary Insurance Subscriber is employed by:
Your answer
Subscriber address, if different from above (Secondary Insurance):
Your answer
Secondary Provider phone number, or phone for mental health or behavioral health benefits:
Your answer
Submit
Never submit passwords through Google Forms.
Forms
This content is neither created nor endorsed by Google.
Terms of Service