New Client Request Treatment | CounSoul with Joe

First name

Last name

Email

Phone

Name you go by

Date of birth

Month

Day

Year

Who would be receiving care?

Me

My partner and me

Someone else

Name of Person Receiving Care

Date of Birth of client receiving care

Month

Day

Year

What mental health concerns or treatment have occurred in the past?

In therapy now

In therapy in the past

Taking psychiatric medication now

Taken psychiatric medication in the past

Hospitalized for mental health reasons now or recently

Hospitalized for mental health reasons in the past

Known neurologic or genetic disorder

Attempted suicide in the past

Other

Payment method How do you plan to pay?

Out of Pocket

Insurance

Employee Assistance Program (EAP)

I'm not sure yet

Is there anything that the practitioner needs to know? For example: what you'd like to focus on, insurance or payment questions, etc.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.