Southeastern Psychological Associates Therapy INTEREST FORM

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Southeastern Psychological Associates provides behavioral, talk and play therapy services for children 4 and up, teenagers and adults. We are located at 3155 Mill Street NE, Covington, Georgia. We accept most Medicaid/Medicare plans, Tricare, and most private insurance, but you should check with your insurance provider for specific coverage and costs. This is not a guarantee that we have current availability. After filling out this form, we will let you know if we are able to schedule you at this time.

We are not an emergency facility. For emergencies or other mental health referrals, call the Georgia Crisis & Access Line at 1-800-715-4225. We do not provide medication management.

Call us with questions at 678-712-6520, Monday through Thursday from 9 a.m. to 4 p.m., or email consumer.relations@sepsych.com.

Client's name - Last, First (one per form) *

To include a nickname: Brown, Charlie "Chuck"

Date of Birth Must CURRENTLY be at least 4 years of age. *

YYYY

If client is under 18, list the parent or legal guardian to contact:

Address *

Our service area is Newton, Rockdale, Walton & Jasper Counties

Cell Phone *

We use text messaging. If this is a home phone or you otherwise cannot receive texts from us, note that by your number.

E-mail *

Your paperwork will be sent to this e-mail.

Insurance (type & ID number) or "none" *

Why are you interested in therapy? *

Please list your current symptoms or concerns, as well as any prior mental health diagnoses or substance abuse concerns.

When are you available for therapy?
Mark all that apply. *

mornings (before noon)

afternoons (12-4 p.m.)

evenings (4 p.m. or later)

Weekdays (Mon-Thurs)

Weekends (Fri-Sun)

Required

Which format(s) are you willing to use for therapy?
Virtual is most often only available for people 16 years old and up. If you begin as a virtual client, you will mostly likely remain virtual and be unable to later swap to in person. *

In person

Video/virtual (phone or computer)

Required

Has this client ever been a client at Southeastern Psychological Associates? *

Yes

Is this person currently seeing any other mental health therapist for behavioral, talk or play therapy? *

Yes

Other:

I understand that (please check all): *

SEPA assists clients with specific mental health needs and symptoms. SEPA sees clients with ADHD, autism, etc., but their role is to assist with issues and skills such as time management, anger/frustration, anxiety, and other specific behaviors.

If I am seeking a diagnosis to be used for medication purposes at another practice, or for an IEP, 504 plan, etc., I understand that the assessment provided by SEPA may or may not be accepted by the other agency. You should consult that agency/provider for more information on what they require. SEPA does not provide in-depth ADHD testing.

If I am seeking specific types of therapy or services, I should inquire about the details before scheduling an appointment for an intake.

Upon completion of this form, I will be contacted within one week to either schedule an initial intake and complete other paperwork, or to let you know if SEPA is currently unable to meet your needs.

If I need immediate, emergency mental health assistance, I should contact the Georgia Crisis & Access Line at 1-800-715-4225.

Required

To complete your interest form, we need a photo of the client or parent/legal guardian's ID and a front & back copy of your insurance card(s). If there are custody/guardianship papers applicable in this case, those must also be sent. Text the photos and the client's name to 770-686-7313‬ or use one of the following options. *

I texted the client's name and card photos to 770-686-7313

I e-mailed the client's name and both photos to consumer.relations@sepsych.com

I will visit the office at 3155 Mill Street NE, Covington, Georgia, to have a physical copy made of my cards.

Other:

REFERRAL INFORMATION: (optional)
If you were referred by someone, or believe your doctor may have already sent files regarding this client, please list that information here.

If you are referring a client to us, please include your name, agency/business, e-mail and phone.

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