Therapy UnPlugged Intake Form – Connections Unplugged

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Intake Form

Relationship of person filling out this intake form for minor patient*
Define "other" relationship of person filling out intake form for minor patient*
Guardian's Name*
First Last
Primary Address*
Street Address Address Line 2 City State ZIP Code
Guardian's Phone Number*
Best Contact E-mail Address*
Age Consent of a Minor Patient 17 years and younger or a Disabled Patient with a Healthcare Proxy*
By checking this box I consent that I am the legal guardian of the patient seeking treatment and that I am filling this information out on behalf of the patient.
Client's Name*
First Last
Client's Date of Birth*
Please note that we do not see patients under the age of 8 years or over the age of 64 years.
Month
Day
Year
Client's Gender*
Please define "Other" Gender*
Client's Academic Grade*
Client's Classroom Teachers at The Discovery School*
Email & Appointment Reminder Communication Consent*

I agree to receive practice updates and session updates via email.
How were you referred to Adria Forte, LMHC?*
- Primary Care Physician or Specialist
- Friend/Family
- Ms. Ellen, TDS Guidance Counselor
- TDS Administrative Team
- TDS Teaching Team
- TDS Support Service Team (Occupational Therapy, Speech Therapy, ABA)
Is your child currently seeing a psychiatrist and/or therapist or have they seen one in the past 6 months?*
Name of Current or Most Recent Psychiatric Treatment Provider*
First Last
Phone*
What type of therapy best fits your situation?*
Please check all that apply.
- Cognitive Behavioral Therapy Lessons at The Discovery School
- Academic Accommodations/Social Skills Support at The Discovery School
- Virtual Parent Support Sessions
- I am not sure
Have your child ever been diagnosed and/or treated for the following?*
If filling out for a minor child, please check any diagnoses they have received in previous treatment. Please bring copies of any evaluations or past medical record to the initial appointment at our office. *PLEASE NOTE THAT OUR FACILITY DOES NOT SPECIALIZE IN TREATING THE DISORDERS WITH (*) SYMBOL AND WILL REFER OUT TO ANOTHER PROVIDER THAT DOES SPECIALIZE IN THESE AREAS.
- ADD/ADHD
- Anxiety Disorder
- Autism
- Depression
- Bipolar Disorder
- Sensory Processing Disorder
- Diagnoses involving Developmental Delay
- Medical Diagnoses impacting social, emotional, physical functioning
- Body Image/Disordered Eating
- Mood Disorder
- OCD
- PTSD
- None
Insurance/Payor Source*
Insurance Policy Name*
Member ID / Policy Number*
Insurance Group ID*
Health Insurance ID Card*
Please upload the FRONT AND BACK of your health insurance ID card
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 16 MB.
Reason for Seeking Services*
Please describe, in detail, the reason you are seeking care. Include any symptoms and when they started.

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