*All information submitted is confidential and maintained on our secure website Please fill out the form below Today's Date Date Format: MM slash DD slash YYYY Your Name:*Email:* Check here to receive email updates Phone:*Referral Source:Client Name:Date of Birth Date Format: MM slash DD slash YYYY Concerns and Reasons for this Appointment RequestIf currently in school, please note the school district and current grade:Is the client transitioning from a higher level of care (ie. inpatient or partial hospital/intensive outpatient program)?NoYes ***(please note that we will need to speak with the referring provider in order to determine the current treatment needs before scheduling an initial appointment.)Parent/Guardian Relationship Status:MarriedSeparatedDivorcedSingleN/A (For adults seeking treatment)If separated or divorced, please identify degree of current conflict with other parent:NoneLowMediumHighExplanation of "degree of current conflict" with other parent:Is the other parent in agreement with this request for the child's therapy? (unless a custody agreement communicates otherwise, our agency requires the consent of both parents for therapy to begin)YesNoN/A (instances where parents are married or potential client is an adult)Does the referred client struggle with any aggression toward him/herself or others? No Yes If aggression toward self or others exists, please explain or share with our intake specialist when you are contacted:Any current or past substance abuse? (types of substances used, was treatment suggested or received?)Type of Therapy Requested Individual Therapy Family Therapy Group Therapy Parenting/Support Group Would you like to receive periodic updates about FRDC groups, resources, etc? (all emails are sent confidentially) Yes No Payment Source:Self PayAnthem BC/BSHuskyAnthem/Husky ID#Policy Holder Name:Policy Holder DOB Date Format: MM slash DD slash YYYY Today's Date Date Format: MM slash DD slash YYYY
