New Client Inquiry

Thank you for considering Aspen Therapy Collective. This questionnaire will help to see if we have a therapist with openings who potentially matches your needs at this time. Please answer the questions based upon the person seeking care (ie. yourself or your child). We will contact you shortly for next steps.

*Sometimes our replies end up in Spam - please be sure to check if you haven't heard back from us.

Name of person seeking therapy

Date of birth and Age

Parent names (if applicable)

In a couple sentences, please describe the reason you are seeking counseling for yourself (or your child) at this time.

Address (including city)

Email address (of primary person to contact to arrange services)

Is it ok to contact you via Email?

Yes

Phone Number (of primary person to contact to arrange services)

Is it ok to leave a voicemail?

Yes

Have you (or your child) experienced suicidal or homicidal thoughts, or been hospitalized for mental health in the past 6 months? If so, please describe.

Have you, or child, ever experienced, or do you have concerns with, the following?

Eating challenges/disorder

Drug/alcohol use

Sensory processing

Autism Spectrum Disorder

Developmental/Intellectual Disability

Attention/focus issues

Anxiety

Depression

Trauma

Something else not described above/or more information about anything checked above

Do you plan to use your health insurance?

Yes

Plan

Include company, plan name, etc.

Member ID

Primary insured name and date of birth

Do you have a preference for therapist, and if they are not available, are you willing to see another? (Please note that Alyssa is not currently accepting new clients at this time).

You may see therapists on staff under "about"

We offer both telehealth and in person services. Please indicate which you prefer.

Therapy for a child/adolescent:

Please describe the custody arrangement and parenting plan

I am married to my child's other legal guardian/parent.

I am divorced from my child's other legal guardian/parent.

I have never been married to my child's other legal guardian/parent.

I am the sole adoptive parent/guardian of my child

Child is in DHS custody

I am 15 years or older

None of the above describe our family situation. Please describe:

Please list any other information you'd like us to know:

Aspen Therapy Collective participates in the Essential Safety Net Provider program, administered by the Behavioral Health Administration. We are required to ask questions related to non-medical needs and demographics. You are not required to answer and your answers to these questions will not impact your ability to receive services from us. With your consent, we can offer referrals for supports needed.

Housing, Food, Transportation, Utilities

Within the past 12 months, you worried that your food would run out before you got money to buy more.

Often true

Sometimes true

Never true

Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.

Often true

Sometimes true

Never true

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for dailly living?

Yes

In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?

Yes

Already shut off

Safety

Because violence and abuse happens to a lot of people and affects their health we are asking the following questions:

Medical

During the past 12 months have you DELAYED getting medical care because of the cost?

Yes No I don't know

Do you have physical health concerns for which you are not receiving adequate treatment?

Yes No

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