New Client Questionnaire

Integrated Therapy Services NW

If this is an emergency, please call 911 or contact the Pierce County Crisis Line at 1-800-576-7764, the Kitsap County Crisis Line at 1-360-479-3033, or the National Suicide Hotline at 1-800-784-2433. If you have any questions, please call or email our office at 253-460-7248 or info@integratedtherapynw.com.

This form is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services including the giving of medical/ psychological advice. No provider-patient relationship is formed by submitting this form. The use of this form is provided at the users own risk. The completion and submission of this form is not intended to be a substitution for individual medical or psychological advice, diagnosis or treatment. Users should not delay obtaining medical/psychological advice regarding any condition they have and should seek the assistance of their medical provider. Once the form is submitted, our office will email you within a few business days to confirm receipt and advise you of estimated availability to schedule with a provider.

Contact Information

Client's Legal First and Last Name

Preferred Name

Client's Date of Birth

Legal Sex (for insurance)

Male Female

Gender Identity

Pronouns

Client/Parent's Phone Number

Okay to leave voicemails?

Yes No

Person to Contact for Scheduling

Relationship to Client

Phone Number

Okay to leave voicemails?

Yes No

Email Address

Mailing Address

City

Zip Code

How did you learn about ITS?

Do you personally know any ITS therapists/clients?

Insurance Information

Primary Insurance Company

Member's ID Number

Group #

Subscriber Name

Subscriber Date of Birth

Relation to Subscriber

Child

Spouse

Self

Other

Insurance Phone #

Picture of Insurance Card (Front and Back)

Add file

Please upload a file

Secondary Insurance Company

Member's ID #

Group #

Subscriber Name

Subscriber Date of Birth

Relation to Subscriber

Child

Spouse

Self

Other

Insurance Phone #

Picture of Insurance Card (Front and Back)

Add file

Please upload a file

Are you covered under Apple Health/Medicaid If yes, plan MUST be Coordinated Care or Molina to be seen at ITS. We are UNABLE to accept any Medicaid plan we are not contracted with.

Yes No

Are you covered under Medicare? ITS can't see clients with Medicare

Yes No

Reason for Seeking Services

Please explain in your own words the reason you are seeking counseling:

If you selected "Other," please explain. Any information provided helps therapists determine if their experience and credentials match what you are looking for.

Current Concerns

Is anyone in your household currently pregnant, or pregnant within the past 3 years?

Yes No

If yes, who? And when is the due date / was the birth date?

Are you currently experiencing domestic violence?

Yes No

If yes, when was the last incident:

Will gender or sexuality be a topic that is discussed?

Yes No

If yes, please explain:

Will sex, sexual concerns, or sexual kinks/fetishes be frequently discussed?

Yes No

If yes, please explain. Have concerns been addressed by a physician?:

Are you currently having health concerns that are being treated by a physician?

Yes No

If yes, please explain:

Are you currently experiencing suicidal thoughts or self-harming behaviors?

Yes No

If yes, please explain:

Kids Under 18 Years Old

ITS is required to abide by legal parenting plans, guardianship documentation, restraining orders, and related legal documents. We are required to receive consent from any adult with decision-making ability for non-emergency medical treatment for children under 13 years old (RCW 71.34.530), and for children under 18 who are not attending counseling voluntarily (RCW 71.34.650).

Are the client's biological parents married?

Yes

N/A

Is there a parenting plan in place? If yes, a copy is required to stay on file. Please attach, email to info@integratedtherapynw.com, or fax to 253-564-4409.

Yes

N/A

File attachments

Add file

Please upload a file

If bio parents are not together, who has decision-making ability for non-emergency medical treatment?

Both parents

Joint Decision

One parent

Sole Decision

Legal Guardian

Other

N/A

Other Parent/Guardian Name

Phone Number

If none of these options fit your situation, please explain:

Preferences

Therapist Preference

Male Female No Preference

Other Preferences:

Availability - What days or times generally work best for scheduling appointments?
Our office hours are Monday - Friday, 8 AM - 7 PM.

Time

Morning (8 AM -11 AM)

Afternoon (12 PM - 3 PM)

Evening (4 PM - 7 PM)

All Day

Day

Monday

Tuesday

Wednesday

Thursday

Friday

Specific or Other:

Please note, afternoon and evening times are the most highly demanded and will likely result in a longer wait time.

Do you prefer Telehealth or in-person appointments?

Telehealth

Either

In-Person

In order to have a Telehealth appointment, the client must be physically located in the state of Washington due to provider licensure.

In order to receive services sooner, are you willing to schedule outside of your preferred time or method?

Yes No

ITS DISCLAIMER: In-person appointments may increase your risk of contracting COVID-19. Therapy rooms are being sanitized in between every session. Selecting "In-Person" appointments does not limit you from using telehealth services in the future and may be set up at any time.