Intake Form
* Please complete and submit the information below and we will contact you and connect you with one of our therapists.
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Office Location *
Are you interested in medication management with our APN (Advanced Practice Nurse)?
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Are you interested in Art Therapy (in person) with Sarah Siering, LPAT?
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Please check off the following virtual workshop(s) if you would like to register.  Each workshop is $25 to attend and/or to receive the recorded playback.
Please check off which day(s) of the week you are available for appointments.
Please check off the time(s) of the day you are available for appointments.
Were you previously seen by a therapist at Main Street Counseling?
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If you were previously seen by a therapist at Main Street Counseling, would you like to see that therapist again if they have availability?
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Client's Last Name *
Client's First Name *
Insurance Subscriber's Full Name *
Medicare Beneficiary ID (If Medicare is your primary insurance)
Client's Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Email Address *
Full Address (Street, City, State, Zip Code) *
If the client is a minor and the child's parents are divorced with joint-custody, please list additional contact information below (phone & email of 2nd parent) so both parents can complete initial intake forms. (Please put N/A if not applicable) *
Referred By *
Required
Therapist requested - please keep in mind that this does not guarantee that this therapist is accepting new clients.
Insurance *
Member ID *
Please select all that apply for your reasons for seeking counseling *
Required
Please provide any additional information for your reason for seeking counseling services to help us properly place you with a therapist. *
Are you still interested in services if telehealth (video/phone) sessions are the only option at this time? *
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