Renew Counseling

NEW PATIENT INQUIRY

Please fill out the following questions so we may place you with the best professional that suits your personal needs.

First Name (of patient) *

Last Name (of patient) *

DOB (of patient) *

Email Address (of patient) *

Phone Number (of patient)*

Home address (of patient)*

City (of patient)*

ZipCode (of patient)*

Name of person filling out form (self/parent/guardian) *

Reason(s) for seeking treatment today: *

List any treatment that client is currently receiving, or has received? *

Current insurance carrier *

Do you want clinical, biblical, or either counseling?

Which office(s) would like to be seen at (Easton, Fairfield, Shelton, Southbury, Telehealth)?

Is the client currently taking any medication? If so, please provide name. *

What church(s) do you attend?

Did a court order your need for treatment?

Yes

Any current physical aggression or mood swings?

Yes

Any specific requests for professional counselors (name, age, gender, specialty)?

If you were referred by someone, please list their name below.

You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.