New Client Screening Form

Please do not complete this form more than once.

This form should be completed by prospective clients or former clients that have not been seen in more than six months.

Please note that our office is located in Barrington NH.

All information provided should be for the potential client.

First Name

Last Name

Middle Initial

Date of Birth

Pronouns

Were you referred to us by Lyra Health?

Yes No

Does the client have mobility concerns that would make stairs difficult?

Yes No

Is the potential client a minor?

Yes, the potential client is under 18 No, the potential client is an adult

We do need consent from both parents / guardians to treat a minor. Ideally the provider would prefer to meet with any responsible parties before meeting the potential client. If that isn't possible, consent can be given by email / phone but it does need to be received before they can be seen. It is the responsibility of the parent / guardian initiating contact with us to secure that consent.

Name of Initiating Parent / Guardian

Contact Email for next steps

Contact Phone Number for next steps

Did someone refer you to us? If so, who? - Please be specific and include full names if you have them.

When are you typically available for appointments? Office Hours are 9 am - 5 pm Monday through Friday with some clinicians offering limited after hours appointments.

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Before 11 am

Mid Day (11 am - 3 pm)

Late Afternoon (3 pm - 5 pm) this is our most popular appointment window and we cannot guarantee that appointments would be consistently available at these times

Optional: List anything specific about your availability that you think we should know here.

Are you aware of any close friends or family members who are or have been clients of AMH. Please include their name and relationship to you.

Presenting Concerns

Please describe what problems you'd like to address and/or why you are seeking counseling.

Providing details will help the screening go more smoothly. Without enough detail to review the case, your screening will not be processed.

Please describe not only what is going on but how it is affecting your daily life. We are looking for, AT MINIMUM a few sentences with examples.

Please include any diagnoses that you have received or that you believe may be applicable that the provider should be aware of or that may come up during treatment.

What services are you seeking?

Individual Therapy

Family Therapy

Relationship / Marriage Counseling

Please note that for ethical reasons Individual and Family/Relationship counseling cannot be performed by the same provider. In cases where both are warranted two providers will need to be assigned.

Relationships - Please note that we need each member to complete their own screening form in order to complete the review.

List Names and Ages of anyone other than yourself who may attend sessions including all members for relationships/marital counseling.

History of Treatment

Is the client currently seeing a therapist elsewhere? If so, who?

Has the client received IOP or in-patient psychiatric care in the last 3 months? If so, where?

Is the client currently prescribed any psychiatric medications? If so, please list them and include who prescribes them.

Is the client seeking treatment as a result of a court order?

Yes No

Symptoms

Other:

How frequently do you drink / use drugs and what do you take? This information will be used only for our clinical review to determine fit.

Please note that we do not have anyone on staff that is trained to treat substance abuse, addiction or eating disorders. If any of these is a concern, we may not be a good fit.

Name of Lyra Member

DoB of Lyra Member

Sponsoring Company (if MGBHP please confirm either MGBHP-Employees or MGBHP-Commercial with Lyra before submitting. The wrong one will result in denied claims)

Lyra Code (if applicable)

If you think there is a possibility that you will want to continue seeing the provider after your Lyra covered visits have been exhausted, please provide your insurance information here so we can verify it in advance. If you'd prefer to be discharged at the end of your Lyra coverage, you can select that option under "Primary Insurance Company" below.

Optional. If we are In Network (Anthem, BCBS, Martin's Point, Medicare, Ambetter) you may include an image of your insurance card here. If you do, please choose "Uploaded Card Image" in the Primary Insurance field below. You can add multiple files if necessary

Add file

Please upload a file

Name of Subscriber

DoB of Subscriber

Subscriber's Complete Street Address INCLUDING City & State - must match insurance records

Subscriber ID

Group # (if available)

Please note that if we are not in network with your insurance you will be charged the full service fee on the day of each session. We are happy to provide documentation if you decide to seek reimbursal from your insurance.

Your information will be encrypted.

Alliance Mental Health and Youth Consultation Services, LLC

The purpose of this form is to match your needs and profile to the appropriate provider. It will be reviewed by appropriate staff only. All information submitted will be kept private.