Soundings screening form test Soundings screening test 2020-09-08 Hidden1.4 HiddenDate intake completed: HiddenDate no case made: HiddenClient #: 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?* Yes No Are you interested in online sessions for health reasons?* Yes No Contact InformationLegal name First Last Chosen/preferred name Pronouns Gender Sex (legal status on ID)* Age* Birthdate* Month Day Year Race/ethnicity Address* 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?* Yes No Are you interested in using health insurance to cover therapy?* Yes No Primary InsuranceInsured's Legal Name First Last Insured's Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to InsuredMake a selectionSelfPartnerChildOtherPrimary Insurance Company Name Customer 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? yes no Insured's Legal Name First Last Relationship to InsuredMake a selectionSelfPartnerChildOtherInsured's BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance Company Name Customer 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?* Yes No If 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? Yes No Are you willing and/or comfortable with seeing a male therapist? ok not ok maybe Are you interested in short-term therapy (10 or fewer sessions)? ok not ok maybe Do you identify as having a disability? Yes No If yes, do you feel comfortable sharing? Do you need any accommodations related to language, accessibility, allergies, etc.? Yes No If 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? Yes No Have you been hospitalized for emotional or psychological issues? Yes No In the past year, have you at any time seriously considered suicide? Yes No Do 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 CAPTCHAHiddenCo-pay (flat fee)HiddenPrimary In-Network Out-Network HiddenSecondary In-Network Out-Network HiddenHiddenPrimaryHiddenSecondaryHiddenYearly deductibleHiddenIn-NetworkOut-Network HiddenIn-NetworkOut-Network NameThis field is for validation purposes and should be left unchanged.