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Directions for Forms:

1) Please complete the New Client Intake and Consent for Services by filling in the sections and clicking submit at the end of each.

2) For questions contact Suzanne, practice manager, at 252-215-9011. 


New Client Intake (Secure and Confidential Submission)

NEW CLIENT CLINICAL INFORMATION

Today's Date

Client Name

Client Date of Birth

Client Age

Client Race

Client Gender

Parent/Guardian Name (If Minor)

Contact Numbers

Email Address

Physical Address (include city and state)

Insurance Type (include person responsible and plan information)

Primary Care Office

Employer or School Name/Grade

Any School or workplace related difficulties

Reasons you are seeking counseling

Initial Goals

Appointment/Provider Preferences/Accommodations

History of Medical Conditions

Developmental Delays/Conditions

Social or Communication Concerns

History of Mental Health Conditions and Treatments

History of Substance-use Conditions and Treatments

Trauma History

Inpatient Admissions (Dates/Facilities please)

Legal Issues or Court Involvement (includes custody)

INTAKE PACKET WITH CONSENT FOR SERVICES

A-CLIENT RIGHTS TO TREATMENT

B-PROTECTED HEALTH INFORMATION

C-APPOINTMENTS

D-SERVICE CHARGES

E-INSURANCE AUTHORIZATION

F-INFORMED CONSENT*

YOUR NAME/SIGNATURE *

TODAYS DATE*


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