Intake Form Step 1 of 5 20% Client InformationName* First Last Date of Birth* MM DD YYYY Address* Street Address Address Line 2 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 Cell Phone*Please provide the best number to reach youEmail* This field is hidden when viewing the formDate of submission MM slash DD slash YYYY Emergency ContactName* First Last Relationship*Phone* Insurance InformationDo you want to use your health insurance?* Yes No Insurance Policy Holder*Choose 'Other' if you are not the primary holder of the insurance policy Self Other Policy Holder's Name*Your Relation To The Policy Holder*Policy Holder's Date of Birth* MM DD YYYY Insurance ID#*Please upload front and back pictures of the insurance cardFront*Max. file size: 50 MB.Back*Max. file size: 50 MB. QuestionnairePlease take a moment to fill out the survey below. Any information you provide to us on this form will be kept in strict confidence. It will not be released to any outside person or agency without your permission. If you do not know how to answer these questions, ask my guidance. Please note, each item refers to your entire life history, not just your current situation, this is why each question begins – “Have you ever…..”1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an emotional problem?* Yes No 2. Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems?* Yes No 3. Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other emotional problem?* Yes No 4. Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?* Yes No 5. Have you ever heard voices no one else could hear or seen objects or things which others could not see?* Yes No 6.A. Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself?* Yes No 6.B Did you ever attempt to kill yourself?* Yes No 7. Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot or stabbed?* Yes No 8. Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending social events, being in a crowd, being alone, being in places where it may be hard to escape or get help?* Yes No 9. Have you ever given in to an aggressive urge or impulse, on more than one occasion that resulted in serious harm to others or led to the destruction of property?* Yes No 10. Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior?* Yes No 11. Have you ever experienced any emotional problems associated with your sexual interests, your sexual activities, or your choice of sexual partner?* Yes No 12. Was there ever a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting, engaging in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up?* Yes No 13. Have you ever had a period of time when you were so full of energy and your ideas came very rapidly, when you talked nearly non-stop, when you moved quickly from one activity to another, when you needed little sleep, and believed you could do almost anything?* Yes No 14. Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you would faint?* Yes No 15. Have you ever had a persistent, lasting thought or impulse to do something over and over that caused you considerable distress and interfered with normal routines, work, or your social relations? Examples would include repeatedly counting things, checking and rechecking on things you had done, washing and rewashing your hands, praying, or maintaining a very rigid schedule of daily activities from which you could not deviate.* Yes No 16. Have you ever lost considerable sums of money through gambling or had problems at work, in school, with your family and friends as a result of your gambling?* Yes No 17. Have you ever been told by teachers, guidance counselors, or others that you have a special learning problem?* Yes No Terms and ConditionsPlease download and review the Privacy Practices and Terms & Condition before responding to the following questions. Click here to download Informed Consent for Treatment*I have read and received a copy of the above information and agree to abide by these guidelines. I hereby consent to my treatment if I am bringing a minor for treatment, I have the legal authority to consent to the minor's treatment and hereby do so consent if the minor is 14 years old or older I understand that the minor will also need to sign this form. I have read and agree to the Informed Consent for TreatmentPrivacy Practices*I have received the notice of Privacy Practices and I have reviewed it. I agree with the Privacy PracticesLate Cancellation Fee*If you are unable to keep your appointment, please give twenty-four (24) hour advance notice. If an appointment is missed or cancelled within 24 hours from the appointment, we reserve the right to charge you Late Cancellation Fee of $75. I agree with the Late Cancellation FeeFinancial Disclaimer*I acknowledge and have read the Financial Disclaimer and agree to its terms. I understand my obligation that payment is due at the time of treatment unless other arrangements are made. I agree that parents, guardians or personal representative are responsible for all fees and services rendered for a treatment of a minor/child or to the patient for whom I have legal responsibility. I hereby authorize Suruchi Saini, LPC, NCC, CCTP to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions, if insurance is used. I agree with the Financial DisclaimerThe Terms and Conditions have been electronically signed by:* First Last Signature*Electronic Signature Consent* I consent to signing this document electronically.