Intake Form - Good Hope Counseling

Emergency Assistance

If this is an emergency, call:

Crisis Line: (800) 273-8255
911

Client Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Street Address

City

Zip Code

Reason(s) for seeking therapy

How did you find out about Hope Counseling?

Medical History

Have you been to a counselor in the past?

Yes No

If yes, please describe the reason for past counseling

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Emergency Contact Information (1 is required)

Add another emergency contact

Insurance Card Type (BCBS, Optum, etc.)

Insurance ID number

Insurance Group #

Insurance phone number ('mental health/substance abuse' or 'for providers')

Insurance Policy Holder First and Last Name

Insurance Policy Holder Date of Birth

I authorize Good Hope Counseling to release information necessary to obtain necessary insurance information to my insurance company. I will get a call from CMBS about my benefits, in-network status, and specific payment information

Yes No

Your information will be encrypted.

Anne Tumborello-Roupas, LCSW, CADC, SAP, NTTS

Licensed Clinical Social Worker, Certified Alcohol and Other Drug Counselor, Substance Abuse Professional, National Tobacco Treatment Specialist, Good Hope Counseling, owner

I am committed to providing client-centered care by fostering an environment of healing. I focus on strength-based, supportive care by integrating cognitive behavioral, DBT, client-centered, and solution focused methods based on the needs of the client. I believe counseling allows clients to reach their goals!

1-630-504-0705, info@hopecounselingpc.org
www.hopecounselingpc.org