Soundings screening form test Soundings screening test 2020-09-08 1.4Date intake completed:Date no case made:Client #:We offer both sliding-fee (based on income) and insurance-based counseling services. If interested in using insurance, we accept the following: Medicare, Blue Care Network of Michigan, Blue Cross Blue Shield, Blue Cross Complete, and Meridian. We also accept out-of-pocket, private pay. How did you hear about us (referral source)?Are you a returning client?*YesNoAre you interested in online sessions for health reasons?*YesNoContact InformationLegal name First Last Chosen/preferred namePronounsGenderSex (legal status on ID)*Age*Birthdate* MM DD YYYY Race/ethnicityAddress* Street Address Address Line 2 City ZIP Code Phone Number (first choice)*Secondary Phone NumberEmail Enter Email Confirm Email Emergency ContactEmergency contact will only be reached in the circumstance: we are unable to reach you by any of your provided means, we are concerned for your safety, or you experience a medical emergency while at our facility.Emergency contact name*Relationship to emergency contact*FriendFamily MemberDoctorCase WorkerPartnerOtherEmergency Contact's Phone*Insurance InformationDo you have health insurance?*YesNoAre you interested in using health insurance to cover therapy?*YesNoPrimary InsuranceInsured's Legal Name First Last Insured's Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to InsuredMake a selectionSelfPartnerChildOtherPrimary Insurance Company NameCustomer Service Phone NumberThis phone number may be an 800 number on the back of your card.Insured ID #Also known as "enrollee ID." May have a 3-letter prefix.Group #This number may be about 8 numerals.Secondary Insurance (if applicable)Do you have secondary insurance you would like to use?yesnoInsured's Legal Name First Last Relationship to InsuredMake a selectionSelfPartnerChildOtherInsured's BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance Company NameCustomer Service Phone NumberInsured ID #Group #Sliding-Scale InformationIf you do NOT want to use insurance and would rather pay a sliding-scale fee please fill out the following two questions.What is your estimated monthly household income?How many people live in your household?Other InformationAvailable days/times for appointment:Best times to contact you:Is it safe to leave a voice mail message?*YesNoIf not, do you feel comfortable sharing why?For the purpose of sending forms online: Do you have access to a computer and/or the Internet?YesNoAre you willing and/or comfortable with seeing a male therapist?oknot okmaybeAre you interested in short-term therapy (10 or fewer sessions)?oknot okmaybeDo you identify as having a disability?YesNoIf yes, do you feel comfortable sharing?Do you need any accommodations related to language, accessibility, allergies, etc.?YesNoIf so, what accommodations?If comfortable, would you share why you are interested in counseling at this time?Are you currently seeking therapy for any of the following reasons (check all that apply): court mandate legal issues (e.g. custody, child support, etc.) to apply for benefits letter of recomendation If comfortable, can you tell us what medications you are currently taking?Have you ever received mental health services before?YesNoHave you been hospitalized for emotional or psychological issues?YesNoIn the past year, have you at any time seriously considered suicide?YesNoDo you need a referral for any of the following resources?Please check all that apply. Health Insurance Dental Coverage Food Resources Primary Care Doctor Housing Assistance Crisis Line Information CAPTCHACo-pay (flat fee)Primary In-Network Out-Network Secondary In-Network Out-Network PrimarySecondaryYearly deductibleIn-NetworkOut-Network In-NetworkOut-Network CommentsThis field is for validation purposes and should be left unchanged.