Client Information Screening Form

Please fill out the following questions to help us understand your needs and determine if we have a provider to meet those needs.

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Name *

First

Last

Email Address *

Are you seeking individual sessions for yourself, family, or individual sessions for each of your children? *

• Myself
• Family
• Couples
• Individual sessions for child/children

Child/Children's ages: *

Any current and/or history of self harming attempts or thoughts? *

• Yes
• No

Important: We are not set up for 24hr support or high-risk services.

If yes, we need to determine risk level and if we are appropriate to meet your needs. Please clarify your yes response. For example, were there any attempts and if so how long ago? If you have a history of self harming thoughts, do they include a plan and have you been hospitalized for anything related to self harm? (how long ago). Are you having self harming thoughts currently? (Please call the 24/7 hotline number at 988) *

current you counseling:

Do you currently use, or have you ever used, alcohol or drugs in a way that has caused concerns or problems for you? *

• Yes
• No

We are moving toward a primarily self-pay payment model. At this time, we still accept insurance for clients in Oregon and some clients in Washington. We are in-network with Blue Cross Blue Shield, MODA, Kaiser, PacificSource, and CareOregon/Health Share/OHP. Will you be using any of these insurance plans? *

• Yes
• No

If yes, specify which one: *

Do you live in the state of Oregon, Washington, Texas, or New York? *

• Oregon
• Washington
• Texas
• New York

How soon are you hoping to start counseling? *

• Within the next week
• Within the next 2 weeks
• Other

If Other, please specify: *

Please provide mulitple options for days/times you are available for sessions: *

Please provide as many options as possible.

Are you comfortable with virtual sessions via a HIPAA-compliant VIDEO platform? We are not offering in person sessions. *

• Yes
• No

In one sentence, please share what you are looking to work on in counseling: *

Do you have preferences for a provider? (Gender identity, cultural background, language, etc.) *

How did you hear about this practice? *

• Referral from a friend/family member
• Online search
• Social media
• Other

If Other, please specify: *

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