Note: Fields in red boxes or written in red text are required.
Do you have health Insurance Information for mental health services?
Have you had past Counseling or Psychotherapy? If yes, please respond below:
Have you had any psychiatric hospital admissions?
Have you previously received, or are you currently receiving any additional services? Ex: TBS, IEP, Wrap services, EPU etc:
Thank you for your cooperation. This information will be helpful in planning services for you. All information on this form is confidential and will not be released without your prior written approval.
Responsible Party :______________________________________________________________
Please print out this page after you have filled it out, then sign it and bring it with you on your first visit.