Whole Mind Counseling New Patient Screening Name * First Name Last Name Sex * Male Female Prefer not to respond Phone * (###) ### #### Email * What day(s) are you available for a FREE consultation? * Check all that apply Monday Tuesday Wednesday Thursday Friday What time(s) are you available for a FREE consultation? * Check all that apply Morning (10a-12p) Afternoon (1p-3p) Evening (4p-5p) INSURANCE COVERAGE Insurance coverage by * BlueCross BlueShield United Healthcare/Optima Cigna Humana Self-Pay Primary Holder: Date of Birth MM DD YYYY SCREEN QUESTIONNAIRE Have you been admitted in a psych hospital over the past 90 days? * Yes No Have you ever attempted suicide? * Yes No If YES, how long ago? Are you involved in court proceedings or foresee to be? * Yes No How long ago and for how long? What is bringing you to therapy? * How Did You Hear About Us? Who referred you to Whole Mind Counseling? Thank you for reaching out! We understand that taking the initial step to therapy can be difficult and we are happy you are here!Someone from our office will be contacting you in the next 24 hours.
