R.E.A.C.H. Counseling New Client Intake Forms

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NEW CLIENT INTAKE FORM

Please fill out this intake form. Upon submitting this form you will be automatically directed to the REACH Intake and Screenings forms. These forms MUST be completed and signed online. These forms need to be completed and signed before you start services with R.E.A.C.H. Counseling. Then you will be contacted by R.E.A.C.H. to schedule your first appointment. Thank you for choosing R.E.A.C.H. Counseling.

R.E.A.C.H. New Client Intake form.

* Indicates required field

Name *

First

Last

Date of birth *

Email *

Phone Number *

If client is under 18yrs, Parent/Caregiver Name *

Clients age? *

Less than 13 13-18 19-25 26-35 Over 36 Prefer not to say

Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender Identity *

Sexual Orientation *

If Other please specify: *

What type of service are you requesting (can select multiple boxes) *

Individual Counseling - Adult Individual Counseling - Child Substance Abuse Recovery Counseling Equine Services (Horse Therapy) located in Fayette Co. Impact 360 - Fitness, Nutrition and Mental Health Not sure although would like more information

How would you prefer to receive services *

Face to Face (in person) Telehealth (over the phone or computer) No preference

Adult - Individual Counseling interested in additional services (Can select multiple options) *

Family Counseling Couples Counseling Unsure would like more information

Child - Individual Counseling Services (can select multiple) *

School based Counseling (counselor goes to collaborating schools) Home based counseling (counselor will come to your home) Office based Counseling Telehealth (over the phone or computer Family based Counseling No preference Unsure would like more information

Which County are you requesting services? *

Substance Abuse Recovery Counseling (can select multiple options) *

Intensive Outpatient SUD Counseling (admission into the IOP supportive housing and recovery services) Out Patient SUD Counseling (recovery services not needing supportive housing) Medical Assisted Treatment SUD Unsure would like more information

If you are requesting R.E.A.C.H. Recovery do you need supportive housing? *

Are you interested in participating in any of the following groups? (can select multiple options) *

Parenting Groups Recovery Groups Parents in Recovery Groups (Child care/groups provided for children) Anger management groups Self Esteem Groups PTSD/Trauma Groups Rise Groups (children and youth, age and gender) Grief Groups LGBTQIA+ Therapy/Support Groups Life Skills groups Codependency Groups Sensory Groups Anxiety / Stress Management Group

Are you interested in Equine (horse) or animal assisted Therapy? *

Brief Summary of Presenting Issue/s: (Please include current diagnoses and medications, if known) *

Goals for Counseling: *

NAME OF YOUR HEALTH INSURANCE COVERAGE (PUT NONE IF NOT INSURED) *

Insurance Member ID *

Would like assistance in exploring possible insurance options? *

WOULD YOU BE SELF PAYING DUE TO NOT HAVING INSURANCE? *

Yes No

Were you referred to REACH? If Yes then by who? *

Are you requesting a specific counselor, if so who? *

How did you hear about this site? *

Internet Search Advertisement Friend Social Media Other

Have you used any non prescribed prescription or non prescription drugs or alcohol within the past 30 days? *

Yes No

Upon submitting this form you will be emailed or texted a link for the Intake and Screenings needed. Please complete and sign these forms. Services will not be able to start unless they are completed and signed.
Thank you for choosing R.E.A.C.H. Counseling!

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