Name *

Best Contact Phone *

Email *

Street Address *

Country *

Enter your country

State *

City *

Postal Code *

Date of birth *

Relationship Status *

Single

Married

Divorced

Separated

Children—names and ages

Current Employment *

Profession/Occupation *

Do you have any language or cultural concerns? *

Yes

Reasons for making this appointment? *

What are the goals you would like to accomplish with our work together? *

Currently, what are your major areas of dissatisfaction in your life? *

Current state of health: *

List current or previous Trauma, Illness, Injury, Surgery and approximate dates or ages: *

Enter name Current Medications/Supplements/Allergies *

Which of the following areas would you consider to be PROBLEM AREAS for you? Mark all that apply. *

Current Stress Level

Health

Body

Exercise

Diet/Food

Recreation/Play

Work/Career

Rest & Relaxation

Finances

Friends

Sexuality

Drug Use

Parents

Children

Marriage / Relationship

Communication

Self-Confidence

Life Purpose

Expressing Feelings

Your Home

Order in Everyday Affairs

Making Changes

Decision Making

Success in Life

Future & Goals

Spirituality

Are you involved in any ongoing substance treatment or recovery program? If so, what? *

Do You have any other problem areas that cause stress, fear or upset? *

I voluntarily agree to participate in counseling.

I authorize the release of any information necessary to my insurance plan or EAP to process claims, determine medical necessity or to request additional sessions and payment of benefits to my provider.

For insurance clients, we need the following information:

Insurance Information

Insurance Coverage:

MediCal

EAP

Other

Out of Network

Deductible

Plan Name

Plan Phone

Insurance ID#

Start

Expires

Sessions Authorized: #

Sessions Authorized: # (copy)

Auth #

Contract Rate: $

Insurance Billing Address

Please sign, if using your insurance or employee assistance program:

“I authorize the release of any information necessary (including notes, treatment summaries and diagnosis) to my insurance plan or EAP to process claims, determine medical necessity, or to request additional sessions.”

“I authorize payment of benefits to my provider.”

Client Signature

I agree that I have read and understand the information provided below: *

Telehealth

Carelon Member Rights

Carelon Privacy Practices

Date *

I agree that my typed name is the electronic equivalent of my handwritten signature and that it represents my intent to sign this document. *