New Leaf Counseling Services by Keith Wilson, MS, LPC, NCC, a LLC Company

New Leaf Counseling Services by Keith Wilson, MS, LPC, NCC, a LLC Company

Client Information and Pre-Psychosocial Intake Form to be completed by client before the first appointment.

Legal Name of client:______

Preferred Name of client:______

Date: ______Age:______Date of Birth:______

Sex: [ ] male [ ] female [ ] questioning or transgendered

Last 4 digits of social security number: *** - ** - ______

If client is under the age of 18 list the name of custodial parents or guardians:

______

Relationship to client: ______

Do you have legal custody rights to seek treatment if the client is an minor?

[ ] yes [ ] no

Phone number:______

Alternate Phone number: ______

May a message be left on the above listed number(s)? [ ] yes [ ] no

Address of residence: ______

City: ______State:______Zip:______

Will New Leaf be billing Medicaid? [ ] yes[ ] no

If so please provide the client’s Medicaid (DCN) #:______

Has the client sought mental health services elsewhere or ever been hospitalized for mental health reasons? [ ] yes [ ] no

If so with whom or where did these services occur and during what dates?

______

______

Is the client currently suicidal? [ ] yes [ ] no

Is there a history of suicidal thoughts/ actions? [ ] yes [ ] no

Can you briefly describe the current problem, situation(s), and/or symptoms?

______

______

______

______

______

______

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______

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Please describe or list any current or past medical problems:

______

______

How did you find out about us?______

By signing below you agree to treatment and consent for New Leaf Counseling Services by Keith Wilson (LLC) to conduct mental health counseling and psychotherapy services on the client listed on page one of this document. By signing you also agree that you understand your rights under HIPPA law, that you have read the consent to treat form and understand all policies associated and prescribed to by New Leaf Counseling, that you understand by reading this that you have a right to print or view “Client’s Bill of Rights” at our website, and that you give us permission to use your information to bill medicaid or other insurance that you might be using.

______

Printed name of client

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Signature of client (18 and older)Date

or

______

Signature of parent or guardian acting on legal behalf of the client

______

Date

Please present this to your therapist with your photo I.D.