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ABOUT
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COUNSELING
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R.E.A.C.H. Counseling New Client Intake Forms
Impact 360 Health
R.E.A.C.H. Restoration Counseling
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Innovative Couple & Family Counseling
Innovative Individual Counseling
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Starr Commonwealth CTP Trainings
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R.E.A.C.H. PARTNERS
Highland Co. Quick Response Team
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Adams Hope
The Response of Faith in the Addiction Arena
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Faith Based Trauma Session Materials
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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.
WHICH R.E.A.C.H. COUNSELING PROGRAM ARE YOU INTERESTED IN?
*
R.E.A.C.H. Restoration Counseling
R.E.A.C.H. Recovery Counseling
Impact 360 HEALTH
Not sure
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Brief Summary of Presenting Issue/s: (Please include current diagnoses and medications, if known)
*
Clients age?
*
Less than 13
13-18
19-25
26-35
Over 36
Prefer not to say
Goals for Counseling:
*
Date of birth
*
How did you hear about this site?
*
Internet Search
Advertisement
Friend
Other
If Other please specify:
*
NAME OF YOUR HEALTH INSURANCE COVERAGE (PUT NONE IF NOT INSURED)
*
Insurance Member ID
*
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?
*
Have you used any 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!
Submit
ABOUT
CONTACT US
Donate to R.E.A.C.H.
WELCOME TO R.E.A.C.H.
>
WHO WE ARE
R.E.A.C.H. PUBLISHING
>
Art and Gratitude Journals
Church Partnership
OHIO FAITH NET
Join our Team
R.E.A.C.H. Staff Portal
COUNSELING
TRAUMA COUNSELING
R.E.A.C.H. Counseling New Client Intake Forms
Impact 360 Health
R.E.A.C.H. Restoration Counseling
>
R.E.A.C.H. Above and Beyond
Creative Counseling
Innovative Couple & Family Counseling
Innovative Individual Counseling
Christian Counseling
R.E.A.C.H. Recovery Counseling
THERAPY DOGS
TRAINING
Starr Commonwealth CTP Trainings
TRAINING & CONFERENCES
RESOURCES
R.E.A.C.H. PARTNERS
Highland Co. Quick Response Team
>
Adams Hope
The Response of Faith in the Addiction Arena
Social Media and Human Trafficking
Faith Based Trauma Session Materials
ETTIL
COUNTY RESOURCES
>
ADAMS COUNTY
BROWN COUNTY
CLINTON COUNTY
HIGHLAND COUNTY
PICKAWAY COUNTY
ROSS COUNTY