New Client Questionnaire

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Gender

Client is a minor (under 18 years old)

Yes No

Client phone number

Client email address

We use this for our secure client portal, forms & billing.

Address

Primary mailing address; also used for insurance billing.

Preferred communication:

Email Phone Text

Can we send text reminders for appointments?

Yes No

We have multiple office locations, what is your location preference? Therapist availability varies by location

Office within East Central School

Office within Frederic Schools

Moose Lake Office

Telehealth

(online via Zoom)

Do you have a preferred therapist? If so, who?

Who were you (client) referred by?

Parent or Guardian Information

First name

Last name

Phone number

Email address

Relationship to child

Address

Is this parent/guardian responsible for billing?

Yes No

Are there any other parents/legal guardians for this child?

Yes No

Please list name, relationship, email and phone number:

Insurance, payment and billing

How will the client pay for services?

Self-Pay (at reduced rate) Insurance Other

Primary Insurance Carrier

Member ID

Named Insured

Named Insured Date Of Birth

My insurance plan:

Is a high-deductible plan

has a co-pay or co-insurance

Deductible, Co-Pay or Co-Insurance amount:

What is the other method of payment?

History

Has the client previously received therapy?

Yes No

If yes, what is the therapist's name and location?

Is there anything else regarding the client's medical history that we should be aware of?

Is the client currently attending school?

Yes No

Which school, and which grade?

Reasons for Visit

We have a variety of therapeutic techniques and services. Please check any that apply.

Post-Traumatic Stress Disorder (PTSD)

Grief, loss

Trauma

Addiction

Marriage / Couples

EMDR and ART Therapy

Law Enforcement

Veteran

Suicidal Ideation

Describe the reasons for seeking therapy.

Describe any goals or outcomes you hope to achieve from therapy.

Describe any significant life changes or stressful events recently experienced.

Is there anything else you'd like to tell us about?

Your name, person completing form:

Your relationship to client:

Your phone number

Your email address

Email address

Thank you! We will be in touch soon.

Your information will be encrypted.

Monarch Counseling Service

A listening ear, an open heart and a calm spirit to guide you through life's challenges and changes.

320-372-2889
monarchcounselingservice.com
cpopowitz
55744 Beaver Tail Road, Sandstone, MN, 55072