Mental Wellbeing Assessment Form

Request for Service Client Form
Attention:

Please be advised that the Mobile Social Clinic does not provide emergency mental health services. If you are in immediate danger call 911. If you require immediate mental health services please contact Crisis Response Centre (adult 24/7) 204-940-1781 or (youth 24/7) 204-949-4777).
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Caregiver Insurer/Payor

First NameLast Name
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number - Cell

Area CodePhone Number
Phone Number - Other

Area CodePhone Number
Email:
example@example.com
CLIENT INFORMATION *
Client Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Insured
Date Of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Client Pronouns:
Area of need:
Have you had feelings or thoughts that you didn't want to live?
How Often do you have these thoughts?

Over the last 2 weeks, how often have you been bothered by the following problems?

Rows	Not at All (0)	Several Days (1)	More than half the days (2)	Nearly Every Day (3)
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Over the last 2 weeks, how often have you been bothered by the following problems?

Rows	Not at All (0)	Several Days (1)	More than half the days (2)	Nearly Every Day (3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Which Form of Therapy are you interested in?
Days Available for Sessions
On Average: Times you are Available for Therapy Sessions
Fee Service Type
How would you like your therapist to connect with you to arrange initial consultation ?
Any additional information please share below:
We will connect with you to complete predetermination for direct billing Insurance eClaims
INSURANCE COVERAGE
Please note that all fees for service are your responsibility. The level of coverage is dependent on your individual plan, percentage covered and available funds. Keep in mind, every insurance plan is different so there may or may not be coverage, deductible or doctor’s note required.

Even if your plan is eligible for Direct Billing there maybe times when insurance will not pay for your session directly for reasons that are outside of our control.

Any portion of the fee for service not directly paid by insurance for any reason must be paid prior to the start of your therapy session and we will provide you with a receipt which can be submitted to your extended health carrier for reimbursement.

It is a good idea to check with your insurance provider prior to your payment of session to inquire about your plan benefits regarding therapy.

For direct billing Service please review and complete Telus Health eClaim Electronic Transmission Authorization and Consent Form.

All services at Mobile Social Clinic are provided by Registered Social Workers.

Fee For Service - $120.00 per session
Signature
Should be Empty:

Request for Service Client Form

Attention:

CLIENT INFORMATION *

We will connect with you to complete predetermination for direct billing Insurance eClaims