Nexus Intake Form

Full Name- As listed on your insurance card *

e.g. John Smith

Preferred Name *

e.g. Johnny Smith

Who is seeking care- Full Name *

e.g. Doe Smith

Gender- Assigned at Birth *

What is on your insurance card

Gender- Preferred

What you most align with

Pronouns *

e.g. he/him, they/them, she/her, etc.

Date of birth *

Phone *

Email Address *

Address

Street Address *

Country *

State *

City *

Postal Code *

Is the person who is seeking services under the age of 13?

Yes

Parent/ Guardian Name -if applicable (able to leave blank if over 13)

Parent/ Guardian Phone Number

Parent/ Guardian Email

What is the best time to reach you *

e.g. 10am on Fridays

Are you a Private Pay Client

Yes

Insurance Policy Name *

e.g. Kaiser Permanente Gold Select

Insurance Member ID # *

Member id listed on insurance card

Please upload Insurance Front- For individual seeking service *

Click to upload

Insurance Front

Please upload Insurance Back- For individual seeking service *

Click to upload

Insurance Back

If you have Medicaid/Medicare we will still need CC on file

This is in case of certain circumstances but you will be notified in advance before you are charged. This is Ignite's policy. Any accommodations can be spoken of during the initial intake.

Credit Card Front *

Click to upload

Credit Card Back *

Click to upload

Emergency Contact

Emergency contact-Full name *

e.g. John Smith

Emergency contact-Email *

[email protected]

Emergency contact-Phone number *

please enter a valid phone number

Background

What is your job? *

Are you currently employed? *

who currently resides in your house? *

Medical History

Please describe any medical issues *

Are you on any medications, if yes, please list them below *

Have you ever been hospitalized for your mental health? *

PHQ-9

Little interest or pleasure in doing things *

Feeling down, depressed, or hopeless? *

Trouble falling or staying asleep, or sleeping too much? *

Poor appetite or over eating? *

Feeling Tired or having little energy? *

Feeling bad about yourself — or that you are a failure or have let yourself or your family down? *

Trouble concentrating on things, such as reading the newspaper or watching television? *

Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual *

Thoughts that you would be better off dead or of hurting yourself in some way? *

GAD-7

Feeling nervous, anxious, or on edge? *

Not being able to stop or control worrying? *

Worrying too much about different things? *

Trouble relaxing? *

Being so restless that it's hard to sit still? *

Becoming easily annoyed or irritable? *

Feeling afraid as if something awful might happen? *

Nexus Intake Questionnaire

Please take your time on the answers as we want to be able to best help your individualized needs. This must be completed before we can schedule the first session.

What made you come to therapy? *

Are there any symptoms that are particularly difficult that should be addressed *

Do these symptoms impair your daily functioning *

How often do you experience these symptoms? *

How long have these issues been occurring? *

Any history related to the issue will be valuable here

What is your Family's mental health History? *

e.g. father has depression, mother is bipolar

Primary Care Provider Name & Location *

e.g. Cody Stap located in Tacoma 708 Broadway

Any Prescribed medicants w/ dosage & frequency *

e.g. Prozac 20mg/ daily

Any past or significant medical issues contributing to your current mental health condition. *

e.g. I broke my leg and it really messed me up mentally, I was unable to walk for a while and it was really difficult.

Presence of Suicidal Ideation in the past 6 months *

Family & Social Relationships

Please list any family/social relationships that are seen as a strength. *

e.g. My dad Jeff is a strength because he always asks how I am doing and is very supportive

Please list any family/social relationships that are seen as a Stressor. *

e.g. My dad Jeff is a stressor because he always yells at me when I get home.

Any Significant Changes in Family/Social Relationships contributing to mental health? *

e.g. My dad Jeff just got a new partner and it has been a difficult new transition.

Childhood & Adolescent History

Do you have any Childhood or adolescent behavioral concerns? *

e.g. I was disruptive in 6th grade

What was your perception of your life growing up? Environment/family life. *

e.g. It was difficult my parents were very rude and it was difficult living in my part of the neighborhood.

Any Childhood/Adolescent Trauma, abuse, and/or neglect. *

e.g. My brother would bully me as I was growing up.

Cultural/Ethnic/Religious Factors

What are your identified strengths in this area? *

e.g. My family was very supportive because of their religion

What is your perception of your culture, ethnic, or religious influences throughout your life? *

e.g. I was raised Christian but have since gone away from the church.

Any Changes in this area you would like to make? *

e.g. I want to become more spiritual.

Education/ Employment/ Military Background

Any Disability Accommodations in place or needed *

e.g. Need a wheelchair accessible entryway

Highest Level of Education & Further Education Goals *

e.g. High School Education but I want to go back to school for a trade.

Any past or present military affiliation *

Chemical/ Substance Use

Current or Past History of substance use: (Select all that apply)- *

If you reported a past or present use, what substance was used as well as the frequency. *

e.g. Marijuana twice a day for 3 years

What is your perception of your substance use? *

e.g. I smoke marijuana but there is no issue

Prior Mental Health Treatment & Any Coping Skills

Have you had past mental health treatment, if so how was it? *

e.g. I had therapy in the past and I really liked how they used CBT.

Any benefits or setbacks to the treatment? *

e.g. It helped a lot with my eating disorder.

What are some coping skills that work for you? *

e.g. I workout twice a week and it helps immensely.

What are some leisure or recreational activities you enjoy? *

e.g. I thoroughly enjoy biking and I do it everyday

Any Desired change in these areas? *

e.g. I would like to workout more.

What is your goal for therapy? *

e.g. I want to be able to manage my emotions in a healthier manner.

Final Questions & Signatures

In Person, telehealth, or hybrid *

Services Requested *

What has motivated you to look for care? *

e.g. Parents, friend, myself

Click Here- to view therapists

If you have a specific clinician in mind please list them below. (If the clinician is full you may be unable to join this clinician's client list.) You may also leave this blank if you do not have a preference. Your intake clinician will be different from the clinician requested.

Any Additional comments or concerns

Are you seeking Child, Individual, Couples, or Family Counseling? *

How did you hear about us? *

Click box to the Left if you agree to terms listed below.

ABOUT IGNITE PATHWAYS
Ignite Pathways provides personalized, evidence-based mental health counseling to individuals and families in the Greater Tacoma community. Our model is designed to increase access to quality care by addressing community-based barriers to treatment. Our clinical team delivers trauma-informed services that emphasize safety, trustworthiness, collaboration, and respect for each client’s lived experience.

Services are available in person and through secure telehealth platforms, allowing clients to participate in counseling from a private location using a computer, tablet, or smartphone.
EDUCATION, LICENSURE, AND SUPERVISION
Ignite Pathways clinicians hold advanced degrees in mental health counseling or related behavioral health disciplines. Each provider meets or exceeds Washington State requirements for licensure, certification, or associate registration.

Our team includes licensed mental health professionals, associate-level clinicians practicing under approved supervision, and graduate-level interns receiving supervision consistent with Washington State law and professional training standards.
AREAS OF CLINICAL FOCUS
Depression
Anxiety
Trauma and post-traumatic stress
Grief and bereavement
Life transitions
Stress and burnout
Relationship and family concerns
Emotional regulation
Self-esteem and identity development
Mindfulness and meditative practices
METHODS AND TREATMENT APPROACHES
Ignite Pathways clinicians use a collaborative, client-centered approach in which the therapeutic relationship serves as the foundation for meaningful change. Treatment is individualized and culturally responsive.

Modalities may include Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Emotionally Focused Therapy, attachment-based therapy, narrative and strengths-based therapies, mindfulness and somatic practices, play and sand tray therapy, logotherapy, schema-focused and cognitive restructuring approaches, creative and expressive therapies, and trauma-informed culturally responsive care.

All services are provided with attention to emotional safety, client empowerment, and long-term wellbeing.

CONFIDENTIALITY AND LEGAL LIMITS
Clinicians follow professional ethical standards and Washington State law regarding confidentiality. Information shared in counseling will not be released without written authorization except when disclosure is legally required or permitted.

Disclosure may occur in situations including:

Serious and imminent risk of harm to self or others
Suspected abuse or neglect of a child, vulnerable adult, or elder
Court order signed by a judge or judicial officer
Certain lawful subpoenas
Medical emergencies requiring coordination of care
Licensing board or Department of Health investigations
Limited professional consultation with identifying information removed
Insurance or payment-related audits
MANDATED REPORTING
Under Washington law RCW 26.44, mental health professionals are mandated reporters. When there is reasonable cause to believe a child has experienced abuse or neglect, a report must be made to Child Protective Services or law enforcement without client consent.

The purpose of mandated reporting is protection of children’s safety and welfare. When appropriate and safe, clinicians will attempt to discuss the reporting process with the client or guardian.
HIPAA NOTICE OF PRIVACY PRACTICES (SUMMARY)
This section summarizes how your health information may be used and disclosed and how you can access this information. A full Notice of Privacy Practices is available upon request.

Ignite Pathways may use or disclose protected health information for:

Treatment coordination between providers
Payment and insurance billing
Healthcare operations such as supervision, quality review, or audits
Situations required by law, including mandated reporting or court orders

Your rights under HIPAA include:

The right to access and receive a copy of your clinical record, with limited legal exceptions
The right to request corrections to your record
The right to request restrictions on certain disclosures
The right to request confidential communication methods
The right to receive an accounting of disclosures as permitted by law
The right to file a privacy complaint without retaliation

Privacy complaints may be filed with:

U.S. Department of Health and Human Services
Office for Civil Rights
or
Washington State Department of Health
TELEHEALTH INFORMED CONSENT
Telehealth involves the use of secure electronic communication to provide mental health services when the client and clinician are in different locations.

Potential benefits include increased access to care, reduced travel time, and continuity of treatment.
Potential risks include technology failures, interruptions in connection, and rare security vulnerabilities despite the use of HIPAA-compliant platforms.

By participating in telehealth, clients understand and agree that:

They will provide an accurate physical location at each session for emergency purposes
They are responsible for ensuring privacy in their environment during sessions
Sessions will not be recorded without written consent from all parties
Standard confidentiality protections and legal limits still apply
In emergencies, clients should call 911 or go to the nearest emergency room rather than relying on telehealth communication

Do not contact your clinician through text messaging as this is not secure.

Clients may withdraw consent for telehealth at any time and request in-person services when available.
CLIENT RIGHTS AND PROFESSIONAL REGULATION
In accordance with RCW 18.19.060, counselors providing services for a fee in Washington State must be registered or licensed with the Department of Health for public protection. Licensure does not guarantee treatment outcome.

Clients have the right to receive information about credentials and treatment, participate in care decisions, decline or discontinue services, request referrals or second opinions, and file complaints regarding unprofessional conduct.

Washington State Department of Health
Health Systems Quality Assurance Division
P.O. Box 47868
Olympia, WA 98504-7869
Phone 360-236-4700

BILLING AND FINANCIAL RESPONSIBILITY

All clients are responsible for the fees associated with services rendered. Ignite Pathways will submit claims to participating insurance providers. It is the client's responsibility to pay any required co-payments, co-insurance, or deductibles at the time services are received.

We understand that navigating healthcare costs can be challenging, and we are committed to making care accessible. Self-pay options, sliding-scale fees, or reduced-rate services may be available to ensure that a lack of insurance coverage does not prevent access to necessary care whenever possible. This must be approved by our office manager before proceeding.
ACKNOWLEDGMENT
I acknowledge that I have received and reviewed this disclosure statement, HIPAA privacy summary, and telehealth informed consent. I have had the opportunity to ask questions and understand my rights as a client. A copy of this document has been made available to me.

Bot protection

By signing below, I confirm that I am the parent or legal guardian of the above-named child. I hereby give my consent for the collection, use, and disclosure of my child's information as required for the stated purpose, in accordance with HIPAA regulations. I understand that I may revoke this consent at any time by notifying the organization in writing.

Clear

By signing below I acknowledge that all the information provided above is accurate to the best of my knowledge.

Clear