Potential Client Questionnaire

Full Name

First and Last Name

Phone Number

Are you looking for services for yourself or your child?

Self Child

Is this for individual or couples counseling?

Individual Couples

Enter Your Date of Birth

What is the child's name?

What is the child's Date of Birth?

Are you seeking services due to a court mandate?

Yes No

Is the client currently a resident of GA?

Yes No

City and State of Residence

City, State

Is there a preference for a male or female provider?

Male Female No Preference/first available

Is there a preference for in person or virtual appointments?

In Person Virtual No Preference/First Available

If there is no availability for in person, is the client you willing and able to have virtual appointments?

Yes No

Is there a preferred time of day for appointments?

Mornings

9am - 11am

Afternoons

12pm - 4pm

Evenings

5pm - 8pm

No preference/first available

All of the following questions pertain to the person who will be receiving therapy services.

Is the client a Veteran or dependent of a Veteran?

Veteran Dependent of a Veteran No

Do you consider yourself a public figure or high profile client?

Yes No

Select the option that best describes you.

Celebrity/Entertainer/Influencer Professional Sports Athlete Political Figure/Government Official Business Executive/High-Visibility Leader Media Personality/Journalist Clergy/Ministry Leader Other

Describe

Do you anticipate potential role conflicts (e.g., staff, parishioners/congregants, or ministry partners seeking services here)?

Yes No Unsure

Do you have any security needs we should be aware of for in-person visits?

Yes No

Please describe.

Has the client been hospitalized due to mental health issues in the last 12 months? (i.e. depression, self-harming behavior, cutting or scratching, suicidal or homicidal thoughts or behaviors, threatening behaviors or violence towards others)

Yes No

When did the hospitalization occur?

Month and year

Provide more details on your hospitalization.

What specifically leads you to seek counseling services?

(i.e. life transitions, difficulties maintaining and establishing boundaries, avoiding conflict, procrastinating)

What do you hope to accomplish by coming to counseling?

Insurance/Billing Information

Does the client have insurance?

Yes No

Who do you have for insurance?

Enter your Member ID

Is this a Medicare or Medicaid plan?

Medicare Medicaid Neither - Standard Plan

Is the patient the subscriber for the insurance?

Yes No

Enter the full name, phone number and date of birth for the subscriber

Do you have more than one insurance?

Yes No

Who do you have for insurance?

Is this a Medicare or Medicaid plan?

Medicare Medicaid Neither. Standard Plan

If you do not have insurance or your insurance wasn't listed, do you wish to self-pay?

Yes No

If you do not wish to self-pay, are you willing to apply upfront via an application to be seen by our provider at no cost to you if you meet the terms and conditions of the application? More information will be provided based on your selection

Yes No

Is there anything else you would like to share that might help us decide if we would be a good fit for each other?

Your information will be encrypted.

Potential Client Questionnaire

Refinery Counseling Services LLC