Screening Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your age?
*
Please briefly describe what you are hoping to receive help with:
*
Are you currently in contact with or have access to contact a clinician within MSC Counseling Center? If so, what is their name?
Please indicate your therapist preference:
*
Male
Female
No preference
Please indicate the type of therapy you are hoping to receive:
*
Individual
Couple
Family
Do you have insurance?
*
Yes
No
What is your primary insurance? Please include insurance details below. Please include name of insurance company, copay or deductible information, policy number, ID number, group number, etc.
What is your secondary insurance? Please include insurance details below. Please include name of insurance company, copay or deductible information, policy number, ID number, group number, etc.
Is therapy court mandated?
*
Yes
No
Do you need financial assistance?
*
Yes
No
If yes, please provide the following information below: Number of people in your household and ages, combined household income, other assistance you are receiving, etc.
Please check any that apply:
*
Medicaid
SSI
Head Start
WIC
Section 8
LHEAP
TANF
Reduced Lunch
None Apply to me
Are you suicidal? If yes, please call 988. We are not an emergency clinic.
*
Yes
No
The Health Insurance and Portability Accountability Act. The HIPAA Privacy Rule is not intended to impede customary and essential communications and practices and does not require that all risk of incidental use or disclosure be eliminated to satisfy its standards. The HIPAA Privacy Rule permits certain incidental uses and disclosures of protected health information (PHI) to occur when the covered entity has in place reasonable safeguards and minimum necessary policies and procedures to protect an individual’s privacy. The MSC Family Restoration Center (MSC FRC) is a nonprofit 501(c)3 entity engaged in the practice of providing referrals and on-site support for the counselors affiliated with MSC FRC. The PHI of potential clients will be handled in a secure manner and stored in an encrypted and/or secure location. However, potential clients should be aware that their PHI may be used for customary health care communications and practices which play an important or even essential role in ensuring that individuals receive prompt and effective health care. By entering information on this form, potential clients are giving their consent to the use of PHI for the customary health care purposes outlined above.Please indicate your agreement to the HIPAA disclosure by checking “I Agree” below.
I Agree
I Don't Agree
Submit
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