TCS Counseling Intake Form

Next Steps

We will reach out as soon as possible to get you scheduled! In the meantime feel free to reach out with any questions: 717-761-4754

Please submit this form in order to schedule services or to be added to our waitlist. Once we receive your completed form, we will reach out to you as soon as we have availability in order to schedule you for an evaluation.

Client Information:

Client First Name

Client Last Name

Date of Birth

Sex

Preferred Pronouns

Client's Primary Address:

City

State

ZIP

Primary email address

Primary Phone

Additional Phone

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to Client

How would you like us to contact you for scheduling purposes?

Text message

Phone call

Which days/times would work best for you?

Wednesday mornings 7-9 am

Wednesday evenings 4-8 pm

Thursday evenings 4-8 pm

Saturday mornings 8-10 am

None of these work for me

Please write your general availability below

General days/times that would work for you:

Insurance and Billing Information:

Name of person responsible for bills (copays, deductibles, unpaid balances):

Address:

Write "same" if same as primary address above

City

State

ZIP

Phone

If "other," please list here:

Please note that we only participate with the insurances listed above in the dropdown menu.

ID #

Policyholder's Name

Please attach your primary insurance card here Include photos of front and back of the card

Add file

Please upload a file

If "other," please list here:

Please note that we only participate with the insurances listed above in the dropdown menu.

ID #

Policyholder's Name

Please attach your secondary insurance card here Pictures or digital files

Add file

Please upload a file

Caregiving Dynamics & Support Network

Who lives in your home?

Primary language spoken at home:

Are you employed?

Yes No

What kind of work do you do?

Do you have reliable respite care or childcare backup?

Who can you confidently lean on for emotional support?

Spouse/Partner

Family Members

Friends

Parent Support Groups

None

Psychosocial Stress & Symptom Checklist

Over the past 2 weeks, how often have you been bothered by the following problems?

Total Score:

Medical Information

Current or past medical conditions

Write N/A if none

Current or past mental health diagnoses:

Write N/A if you do not have a diagnosis

Current mental health provider(s)

Psychiatrist

Therapist

Other

None

Name/facility of current mental health providers:

Past psychiatric hospitalization?

Yes

If yes, dates/reason:

Current or past substance use?

Yes

If yes, please explain:

Please list any current medications (mental or physical health), including dosage and purpose:

Client Profile

What are your primary goals for your own therapy?

e.g. boundary setting, anxiety management, finding balance

What coping strategies or activities help you feel grounded, if any?

Safety Assessment (Adapted CSSR)

In the past month, have you wished you were dead or wished you could go to sleep and not wake up?

Yes No

In the past month, have you actually had any thoughts of killing yourself?

Yes No

Have you been thinking about how you might do this? Example: "I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it...and I would never go through with it."

Yes No

Have you had these thoughts and had some intention of acting on them? As opposed to "I have the thoughts but I definitely will not do anything about them."

Yes No

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Yes No

Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Yes No

When did this occur?

Describe your actions.

Example: collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, cut yourself

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

What questions or concerns would you like your therapist to be sure to address at your evaluation appointment?

Your information will be encrypted.

TCS Counseling Intake Form

Next Steps

Please submit this form in order to schedule services or to be added to our waitlist. Once we receive your completed form, we will reach out to you as soon as we have availability in order to schedule you for an evaluation.

Caregiving Dynamics & Support Network

Psychosocial Stress & Symptom Checklist

Safety Assessment (Adapted CSSR)

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Next Steps

Therapy and Counseling Services