Client Intake Form v3 - Blue Sails Counseling and Consulting

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Client Intake V3

Updates

Let's find the best option for you

Having a therapist you feel connected to is key. We'll ask you some questions to pair you with a licensed therapist who fits your therapy needs and preferences.

First, please tell us a little about yourself

This information will be kept confidential and helps us ensure we're able to provide you with care.

First Name

Last Name

Phone Number

State

Do you have health insurance?

Yes

Insurance Carrier

What type of service are you looking for?

Individual Therapy

Medical Management / Psychiatry

Both Therapy and Psychiatry

Group

Other

Are you interested in seeing someone faster via telehealth?

Yes

No, please put me on the waitlist for an in person visit

Appointment Type

Adult

Minor

Age of minor

Which of the following best describes what you’re currently experiencing?

Feeling sad or low energy most days

Feeling anxious, nervous, or “on edge”

Difficulty staying focused or completing tasks

Extreme mood changes, from high energy to deep lows

Feeling disconnected from reality, seeing or hearing things others don’t

Trouble managing anger or impulses

Interested in self-care

Something else

Over the past month, how often have you experienced this?

Nearly every day

Several days a week

Occasionally

Rarely

How much does this impact your daily life?

Not at all

Slightly

Moderately

Significantly

Extremely

We can provide you with the personal care you need. Now let’s get you started

By proceeding, you consent to them, and agree to adhere to our Members Rights and Responsibilities terms.

What's the best way for our team to reach out to you?

Phone Call

Text Message

What's the best time to reach you?

Anytime

Before Work [Before 9am]

Mornings [9am - Noon]

Lunch [Noon - 2pm]

Afternoons [2pm - 5pm]

After Work [After 5pm]

By providing a telephone number and submitting this form, you are consenting to be contacted by SMS message. Message & data rates may apply. Message frequency may vary. See Privacy Policy. Reply Help for more information. You can reply STOP to opt-out of further messaging.

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