Counseling Inquiry Form

Counseling location preference*

1417 Oregon Road, Leola
520 E. Birch Street, Palmyra
134 E. King Street, Lancaster
First available
DINA Program (locations to be announced)

My Name*

First Last

Relationship to Client*

Identified Client's Full Name*

First Last

Date of Birth*

Male
Female

Married
Single

Cell Phone*

Home Phone*

Work Phone*

Phone Contact Preference*

Cell
Home
Work

Is Voicemail Okay?*

Yes
No

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Is the client a child?*

Yes
No

Mother's Name*

Father's Name*

Who is the primary caregiver?*

Who has legal custody?*

Is this child adopted?*

Yes
No

Is this a foster child?*

Yes
No

Is this child going to be adopted?*

Is there a legal guardian involved?*

Yes
No

What is the guardian's name?*

Guardian's phone number*

Does the client have other services?*

(IEP, GIEP, TSS, BHRS, family-based, speech or occupational therapy, etc)? If yes, please explain:

Presenting problem(s):*

Addictions:

Other:

Additional information:

Is the client employed?*

Yes
No

Is the client a veteran?*

Yes
No

Is the client a student?*

Yes
No

Name of School:

Current or past therapy?*

Yes
No

Dates/where:

Has client ever been psychiatrically hospitalized?*

Yes
No

Dates:

Previous outpatient treatment by psychiatrist?*

Yes
No

Psychiatrist name:

Psychiatric diagnosis:*

Medications:*

Other current agency involvement:*

Insurance

Do you have insurance?*

Yes
No

Primary insurance*

Plan name:*

Other (if not listed):

ID#:*

Group #:*

Behavioral Health Phone:*

Name of insured:*

Date of birth of insured:*

Do you have secondary insurance?*

Yes
No

Secondary insurance*

Plan name:*

Other (if not listed):*

ID#:*

Group #:*

Behavioral Health Phone:*

Name of insured:*

Date of birth of insured:*

Appointments*

Appointments are weekdays only. Please list specific days of the week and/or times during the day that you are NOT AVAILABLE for appointments:

Counseling Inquiry Form

COBYS Counseling Inquiry Form

Counseling Inquiry Form (1)

Insurance

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