New Client Intake

Name

First Name

Last Name

Date of Birth

YYYY

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referral Source

How did you find out about Good Land Counseling?

Availability

Please provide a description of your general availability (ie., Weekdays after 5; afternoons, etc). I keep office hours Sunday through Thursday.

Preferred Communication

Please check all the ways that are safe and comfortable to communicate with you

Phone/Voicemail

Text

Mail

I would like an appointment reminder by text 72 hours before my appointment.

Primary Concerns/Challenges

Briefly describe the primary reasons you are seeking counseling.

Emergency Contact

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Relationship

Payment and Insurance

Payment

Select how you plan to pay for services. If you plan to use insurance, please enter all the information requested. Please also call the number on the back of your insurance card or check your plan to verify coverage of mental health services for in-network or out-of-network providers. If you select self-pay, we will discuss the standard fee per session at our first meeting.

Insurance Provider

Member Number

Group Number

Relationship to Subscriber