Adult Intake Forms - Greater Atlanta Family Counseling and Atlanta Center for EMDR 
Please find information and forms required to begin services with our agency. 
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Client's Name  *
Date that you are completing this form (click calendar icon below)
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I am seeking services for:

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Required
If you are not the prospective client, but you are filling out this form, please provide your name, relationship to the client, email, and phone number (e.g. Jane Doe, mother, jane.doe@pretendemail.com, 555-555-5555)
Client's phone number  *
Client's email address *
Client's home address:
Client's DOB *
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I am looking to begin services for: *
Required
Payment for Services (please check your priorities) *
Required
Please list your health insurance company, e.g. Aetna, Cigna, Medicare, etc. (Only if you are interested in using health insurance)
For Atlanta Center for EMDR Clients Only:
I would like my sessions to be: *
Required
If you are flexible, please write your preferences below (e.g. 1: Decatur, 2: Marietta, 3: Virtual)
I would like my appointments to occur: *
I would like my provider to be: *
Required
Have you already identified a provider or providers that you would like to work with? If so, please write their name below:
Are you open to the idea of working with a clinical intern if other providers have a waitlist? 

Note:
Our interns can work with Peachstate, Amerigroup, and CareSource, and often operate on a sliding scale, typically from $60.00 - $75.00 per session. 
Sliding scale can be flexible if required (sliding scale applications must be approved by clinical director)
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Do you need psychiatric services/med management? *
In the past month, has the client experienced severe suicidal ideation or made a suicidal gesture or attempt: *
In the past month, has the client had serious thoughts of wanting to hurt others? *
In the past month, has the client had any issues related to self-harm? *
In the past month, has the client been discharged from a psychiatric hospital? *
In the past month, has the client heard voices or seen things that other people do not? *
In the past month, has the client been unable to control their behavior when emotional? *
In the past month, has the client felt like their life was full of chaos or drama? *
Has the client ever been diagnosed with Schizophrenia, Bipolar Disorder, Schizoaffective Disorder, Borderline Personality Disorder, Autism Spectrum Disorder, or an Intellectual/Developmental disorder? *
If you answered "Yes" to the above question, please list the diagnosis or diagnoses:
Has the client ever had significant issues related to eating disorders or body dysmorphia? *
Has the client ever had significant issues related to substance abuse?
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Has the client ever struggled with severe suicidal ideation or suicide attempts? *

Are you currently involved in a legal matter that you would like a mental health professional to participate in, or 

Do you anticipate becoming involved in a legal matter that may require a mental health professional to also become involved?

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Do you need any types of form filled out in the near future, e.g. FMLA, SSDI?
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Please provide a short narrative for your therapy goals: *
NOTE:  IF YOU ARE PLANNING ON USING HEALTH INSURANCE, AFTER YOU COMPLETE THIS FORM, RETURN TO OUR WEBSITE TO COMPLETE AND SUBMIT THE INSURANCE FORM, WHICH CAN BE FOUND AT GAFAMILYCOUNSELING.COM/TAKE-ACTION 
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