Client Information

Client Information

Please enter your first name.
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Please enter your last name.
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Please enter your address.
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Please enter your city.
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State
Please select your state.
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Please enter your zip code.
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Please enter your cell phone number.
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Please enter your home phone number (optional).
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Please enter your employer’s name (optional).
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If different from your legal first name. (optional).
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Description: (optional).
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Please enter how you found out about us (optional).
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May we leave a voicemail?
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May we send text messages regarding scheduling and services?
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Preferred Method of Contact
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Emergency Contact Information

Please enter your emergency contact name.
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Please enter the relationship with emergency contact.
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Please enter your emergency contact’s phone number.
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May we leave a voicemail with this person? 
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May we discuss scheduling matters with this person?
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Insurance Information

Will you be using health insurance for services?
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Please enter the name of your insurance provider.
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Please enter the Member ID exactly as it appears on your insurance card.
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Please enter the full name of the primary insurance subscriber.
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Please enter the Group Number from your insurance card, if applicable.
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Relationship to Subscriber
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Please enter the customer service phone number from your insurance card.
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Do you have a secondary insurance plan?
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Please enter the name of your secondary insurance provider.
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Please enter the Member ID for your secondary insurance plan.
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Presenting Concerns

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How long have these concerns been affecting you?
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Have you experienced these concerns before? 
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Are these concerns affecting any of the following areas of your life?
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Clinical History

Have you previously participated in counseling or therapy?
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Please select any symptoms you are currently experiencing.
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Medications

Are you currently taking any medications?
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Safety Assessment

Have you had thoughts of harming yourself within the past 30 days?
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Have you had thoughts of harming others within the past 30 days?
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Substance Use

Do you currently use alcohol or other substances?
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Consents & Agreements

May we leave a email?
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May we send appointment reminder by text message?
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May we send appointment reminder by email?
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May we send appointment reminder by email?
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Release of Information

Would you like us to coordinate care with other providers?
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Financial Responsibility

I understand that I am financially responsible for all charges incurred for services provided. While Psychological Services for Families may bill my insurance as a courtesy, I understand that I am responsible for any copays, coinsurance, deductibles, non covered services, and balances not paid by my insurance carrier.
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I authorize payment of my insurance benefits directly to Psychological Services for Families for services rendered.
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I understand that missed appointments and late cancellations may result in a fee that may not be covered by insurance.
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I authorize Psychological Services for Families to securely maintain payment information and charge authorized balances in accordance with office policies.
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Consent & Signature

I certify that the information provided in this intake form is true, complete, and accurate to the best of my knowledge. I understand that typing my name below constitutes my electronic signature and constitutes my agreement to treatment, office policies, financial responsibility policies, telehealth policies (if applicable), and the Notice of Privacy Practices.

I have reviewed and agree to the Consent for Treatment, Office Policies, and Notice of Privacy Practices.
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📄 View Office Policies
📄 View Consent for Treatment
📄 View Notice of Privacy Practices
Please enter your full legal name as your electronic signature.
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Relationship to Client
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Psychological and Therapeutic Services Counseling Services for Families and Children • Imagine Help • A Street Intervention Serving Ventura County (805) 487-2244 | info@psforhelp.org