Life's Light in Counseling, Shannon West, LPC   -  Helping you find the Light in your Life

First Time Counseling Appointment Form for Skype, Phone and/or Email
Date
First Name
Last Name
Address (include City, State and Zip)
Phone number
Email address
Date of Birth
Sex
Marital Status
Highest grade completed in school/college
Describe what you would like me to help you with (anxiety, depression, relationships etc..)
When did this issue begin to trouble you?
Have you received counseling for this or any other issue in the past? If yes, please describe it to me
Please tell me what current medications you take (prescribed and over the counter)
In case of an emergency you give me permission to contact the person typed below
Their phone number is
Please tell me what you would like me to help you with.
When did this issue begin to trouble you?
Have you received counseling for this or any other issue in the past? If yes, please describe it to me
Please list all current medications you are taking (prescribed and over the counter)
Have you ever been hospitalized for a mental health issue? If yes, please tell me about it
Please tell me about any current legal issues you are involved in
When was the last time you were examined by a physician? Please list all medical problems you have.
Have you ever received alcohol/drug treatment? If yes, please describe it to me
List two strengths you have and two challenges you have
Please tell me about any family members that have been treated for a mental health issue
Please list any weapons you currently have in your home (This would be used if necessary to assist in your safety or the safety of another
Do you have any learning disabilities that may hinder you from participating in any form of technology-assisted counseling offered (phone, email or Skype) If yes, please explain
Do you need any assistance understanding and/or utilizing the technology you will be using to participate in technology-assisted counseling?
Do you have the technology capable of supporting the type of technology-assisted counseling you are requesting? Do you need help determining this? Please type your question/concern below
Most insurance companies do not cover technology-assisted counseling. If you would like to give me permission to check your mental health insurance coverage to see if it covers technology-assisted counseling? If yes, please provide the following information. If no, please state the method you will use to prepay
Full Name of Insurance
Address of Insurance
Phone number of Insurance
Insured's Name
Insured's DOB
Insured's Employer
Member ID #
Group #
Signature of Client or Client's Guardian
Date
*This information will be used for treatment and for the filing of insurance. Any other use will not be undertaken without the written consent of the client/client's guardian

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