Person 1 Information

Preferred Name (Person 1)

First name

Last name

Pronouns

Legal Name (Person 1)

As listed on insurance.

Legal First Name

Legal Last Name

Date of Birth

Email

Phone

Is it okay to leave a voicemail at this number?

Yes

No 2

Person 2 Information

________________________________________________________

Preferred Name (Person 2)

First Name

Last Name

Pronouns

Legal Name (Person 2)

As listed on insurance.

Legal First Name

Legal Last Name

Date of Birth

Email

Phone

Is it ok to leave a voicemail at this phone number?

Yes

No

Additional People in Therapy

________________________________________________________

Names, ages, email addresses, and phone numbers of others that will be joining in session.

What is the structure of your relationship?

Preferred communication method:

Call us.

Email us.

________________________________________________________

How will you be paying for therapy?

Upload your Insurance Card - front & back

If you do not have your physical OHP card, please provide your OHP ID Number:

Are you covered by a secondary health plan? i.e. insurance through work, school, parents, etc.

________________________________________________________

For the following question, please check all that apply to your degree of comfort. This list is not meant to be conclusive, but can give me a sense of how I can help.

We're interested in working on:

Please share a brief summary of what brings you to therapy.

Have you been in therapy before?

Yes

No

________________________________________________________

The follow questions are asked to ensure that Brave Ass Scaredy Cat Counseling can honor your level of care. Thank you taking the time to share intimate info.

Person 1

Person 1: Have you currently or recently had suicidal thoughts?

Person 1: Have you currently or recently engaged in self harm? if yes, please share. (such as burning, scratching, cutting, hitting self).

Person 1: Are you taking any medications at this time? This can be for medical or psychiatric reasons. If yes, we will follow up at your first session. I take a holistic approach to your treatment and coordinate with your current care providers as needed.

Yes

No

Person 2

Person 2: Have you currently or recently had suicidal thoughts?

Person 2: Have you currently or recently engaged in self harm? if yes, please share. (such as burning, scratching, cutting, hitting self).

Person 2: Are you taking any medications at this time? This can be for medical or psychiatric reasons. If yes, we will follow up at your first session. I take a holistic approach to your treatment and coordinate with your current care providers as needed.

Yes

No

___________________________________________________________________

What is your general availability for scheduling?

If Brave Ass Scaredy Cat Counseling has no availability at this time:

I'd like to be placed on my their waitlist.

I'll keep searching for a therapist elsewhere.

How did you hear about Brave Ass Scaredy Cat?

Telehealth (video calls) therapy sessions are limited. In-person sessions are Brave Ass Scaredy Cat Counseling's primary availability at this time.

I'm down for in-person.

I only want to meet via telehealth.

Any questions or anything else I should know?

Relationship Therapy

Person 1 Information

Preferred Name (Person 1)

Legal Name (Person 1)

Person 2 Information

________________________________________________________

Preferred Name (Person 2)

Legal Name (Person 2)

As listed on insurance.

Additional People in Therapy

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

The follow questions are asked to ensure that Brave Ass Scaredy Cat Counseling can honor your level of care. Thank you taking the time to share intimate info.

Person 1

Person 2