Child Initial Intake Questionnaire

Child's First Name

Child's Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Your Email:

Your Phone Number:

Is it okay to text you at this number?

Yes

Father's First Name

Father's Last Name

Mother's First Name

Mother's Last Name

Who does the Child live with?

Child's Gender:

Child's Age:

Child's Birthdate:

Child's SSN:

Child's School:

Current Grade:

Any Involvement with the Children's Division/Juvenile Office/Court/Legal Disputes?

Yes

Please Explain Legal/Court/Children's Division Involvement:

Who referred you for counseling?

Child's Personal Physician:

Last Seen by Physician:

Child's Current Medications:

Does your child have any Food or Medical Allergies?

Food Allergy

Medical Allergy

None

Known Food Allergies:

Known Medical Allergies:

Has your child had previous contact with a Mental Health Professional?

Yes

Has your child had suicidal ideation?

Yes

I don't want to answer

Has your child ever been hospitalized for mental health?

Yes

I don't want to answer

Who did you see previously for mental health?

When did you see them? For how long?

Where did you see them?

Please tell me more about your child's suicidal thoughts. When?

Please tell us more about your child's hospitalization: (when, where, why, etc.)

Why are you seeking counseling?

Does your child want to attend counseling?

INSURANCE VERIFICATION
& ASSIGNMENT OF BENEFITS
I understand I am responsible for the hourly rates for services listed below:
Initial Session/Intake assessment- ~~$100~~ $50
Individual therapy-~~$75~~ $50
Marital/Family therapy-~~$100~~ $75

Zac Erisman is a contracted provider through the following Missouri Insurance Plans:
CIGNA United Health Care Missouri CARE Home State Health

The method of payment I intend to use:

Self Pay

Missouri Medicaid (MC+)

Commercial Health Insurance

Insurance Company:

Policy/ID Number:

Group Number:

Insured's Name:

Insured's Employer:

Insured's SSN:

Insured's Relationship to Client:

Phone Number for Insurance Company:

Date Input

Signature

Date Signed

Adult Initial Intake Questionnaire

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Gender

Marital Status

Phone Number

Is it okay to text you at this number?

Yes

Your Age:

Birthdate

SSN:

Employer/School:

Highest Level of Education Completed:

Any Court Involvement/Legal Disputes?

Yes

Please Explain Your Court Involvement or Legal Disputes:

Who referred you for counseling?

Personal Physician:

Last Seen by Physician:

Current Medications:

Do you have any Food or Medical Allergies?

Food Allergy

Medical Allergy

None

Known Food Allergies:

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Known Medical Allergies:

Have you had previous contact with a Mental Health Professional?

Yes

Have you had suicidal ideation?

Yes

I don't want to answer

Have you ever been hospitalized for mental health?

Yes

I don't want to answer

Who did you see previously for mental health?

When did you see them? For how long?

Where did you see them?

You said you previously had suicidal thoughts. When?

Please tell us more about your hospitalization: (when, where, why, etc.)

Why are you seeking counseling?

The method of payment I intend to use:

Self Pay

Missouri Medicaid (MC+)

Commercial Health Insurance

Insurance Company:

Policy/ID Number:

Group Number:

Insured's Name:

Insured's Employer:

Insured's SSN:

Insured's Relationship to Client:

Phone Number for Insurance Company:

Date Input

Signature

Date Signed

You can fill out these forms online Below or print them using the links below:

(ADULT FORMS CAN BE FOUND AFTER THE CHILDREN FORMS)

Child Initial Intake Questionnaire

Adult Initial Intake Questionnaire

The following forms will also be filled out during our first session:

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