New Inquiry Intake Form

1
Name
First Name
Last Name
2
Email
example@example.com
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number
Area Code
Phone Number
5
Alternate Phone Number
Area Code
Phone Number
6
Date
Date
Month
Day
Year
7
Time
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
8
What Insurance Type/Name will we be authorizing for you?
9
Services Please Select The Service(s) That You Would Like Us To Assist You With
Individual Psychotherapy
Support Group (s) - please select your group on the following Page
Couples Therapy
Life Coaching
CBD Consultation
Health and Wellness Evaluation and Consultation
Reiki Healing
BrainTap
Weight Loss Program
Bariatric Evaluation
Family Therapy
10
Please Select Support Group (s)We offer support groups throughout the year. Please Select The Groups You would Like To Join . Fees vary depending on group selected. Groups run between 4-8 weeks. Discounts available if you register more than one person for the group.
Grief Support
Relationship Support
Weight Loss Support Group
Couples Support Group- 3 couples , maximum, per group
What’s Your Love Language - Relationship Support Group (International Mental Health Counselor)
Anxiety Support Group
Trauma Support Group
Mindfulness Workshop
Depression Support Group
11
Who are the services for?
Self
Child
Parent/Senior
Family
Spouse/Partner/Significant other
12
Who referred you? : Dr. (add doctor’s name), Insight Wellness Website, Psychology Today, Web Search, Friend , etc...
13
Date of Birth and age of person (s) seeking services
14
Are you in a relationship? If so specify: yes, no, married , dating , etc..
15
Are you presently employed?
16
May we call you on your cell phone or leave you an email (both). Please specify.
17
Brief description for seeking services (you may expand your answer below)
18
Have you been seen by someone for these issues or concerns in the past and if so please specify
Consultant
Psychiatrist
Psychotherapist
Primary Care Physician
Coach
Other
19
Physician's name
20
Psychiatrist’s name
21
Have you been hospitalized? If so please provide name, date and reason for hospitalization
22
Please check all that apply
Pain
Difficulty or changes in Sleep patterns
Depression
Anxiety
Trauma (present or by history)
Sadness
Stress related to work
Physical or emotional abuse
Alcohol abuse
Drug use or abuse
Self Harm
Suicidal Ideations ( please go to your nearest emergency department; call 911; seek immediate medical attention for support . Emergency Suicide Hotline number is: 1-800-273-8255
Domestic Violence
Court appointment therapy
Eating Disorder
Health and Wellness Lifestyle changes to include Lab review and Supplement for Alternative Therapy or Alternative Medication?
Grief / Loss
23
Other areas of concern not mentioned above?
24
What would you like to accomplish ?Goals
25
Additional Information that may help us help you.
26
Please Check here if we can email you our newsletter or upcoming community events, education, wellness information and presentations.
Yes
No
27
Thank you for completing this initial intake form. Our Intake coordinator will be contacting you to further discuss. Our goal is to set you with the best therapist, coach or counselor that meets your specific needs.

Please complete the Pre-authorization Registration link located on the forms page of our website. This will help us pre-authorized any insurance and /or register you as a client/patient for our center.

Pleae complete the payment and credit card section as well. This can be found on the forms page of our website. You will receive instruction from our intake coordinator on this to help you in any way we can.

Do not hesitate to call us with any question you may have. We can also assist you in filling out this form together online, by phone, by video conferencing or at our center with a set and complimentary appointment set aside for you to see the center and ask any further questions.

Thank you
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