Adult Intake Step 1 of 6 16% Name(Required) First Last Age(Required)Please enter a number from 0 to 100.Please enter your age.Date of Birth(Required) MM slash DD slash YYYY Sex at Birth(Required) Male Female Prefer not to say This is for the purposes of billing your insurance company. If you prefer not to say or do not plan to use your insurance, please select “prefer not to say”.Email(Required) Phone(Required)Current Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Would you like to use insurance?(Required) Yes No Insurance Company(Required) Insurance ID(Required) Policy Holder's Name(Required) Policy Holder's DOB(Required) MM slash DD slash YYYY Do you have secondary insurance?(Required) Yes No If you have a secondary insurance policy and fail to supply that information, you may be held responsible for the full balance of sessions.Insurance Company(Required) Insurance ID(Required) Policy Holder's DOB(Required) MM slash DD slash YYYY Are you currently in therapy?(Required) Yes No Have you been in therapy before?(Required) Yes No Most recent time in therapy? MM slash DD slash YYYY Have you had previous hospitalization for mental health or substance use concerns?(Required) Yes No If yes, please explain: Are you currently taking psychiatric medications for: Anxiety Depression Other Please list your current medicaitons: Are you currently facing legal action(s)?(Required) Yes No Please explain: Please give us a brief description of your concerns and goals for therapy.(Required)If you would like to request a specific counselor, please indicate belowNo preferenceJamie GaddyCorey HindmanTayha SmithCatherine WarrenSusanne WillisKatie DavisJames McIntyreHow were you referred to us? If you were referred by someone in the community (counselor, nurse, doctor, attorney, etc…), please let us know here Please let us know what days of the week (Monday through Saturday) and what times (morning, afternoon, evening) might be most suitable for your appointments.We cannot guarantee an appointment time until you’ve scheduled your first appointment but this will help us match you with one our counselors based on availability. CAPTCHAOnce you have completed this form a member of our team will contact you to inform you of our placement procedures. Thank you for allowing us to assist you. We look forward to working with you.
