New Client Questionnaire

Torrie Gilden, PhD, LMHC, SUDP

Please correct the errors described below.

Emergency Assistance

If this is an emergency, call:

Crisis Line: 800.852.2923
911

Client Information

First name

Last name

Home phone number

Cell phone number

Street Address

City, State, Zip

Email address

Date of birth

Counseling History

Have you ever attended counseling previous to now?

Yes No

If yes, please describe your experience. Include the name of your previous counselor/s, how long you worked with them, what you found most helpful, and any previous diagnoses (if known).

Date available to begin counseling

Do you have insurance?

Yes No

If yes, who is your insurance provider?

If yes, please provide insurance information. Including, primary insured party, insurance #, group number, primary insured phone #, employer, insurance phone #, and any secondary insurance information.

Please describe what is bringing you into counseling.

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

Emergency Contact Information

Add another emergency contact

Preferred Method of Communication

Phone Call Text Email

Therapist Gender Preference

Female Male No Preference

Preferred Setting

In-Person Telehealth

Your information will be encrypted.

Emergency Assistance

If this is an emergency, call:

Crisis Line: 800.852.2923
911

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