Please answer all questions that pertain to you. You may choose to have a copy of your completed form sent to your email by checking the toggle at the end. You may also request a copy of the completed form be shared with you using more secure means than email.

Some questions will require an answer, those with red stars. Please enter "none" or "not applicable, n/a" if you have nothing to input.

This completed form will become part of your record. Some of these questions involve very private information. Google Forms as employed by this practice is more secure than email, and in many ways, more secure than voice communication (which must be noted for input into the computer system). The information is stored directly into the practice's Gsuite storage, which  is protected by HIPAA-compliant security.

This practice uses one intake form for all clients, regardless of whether they pay by insurance or fee-for-service. Many of the questions are required by insurance companies--which all have different requirements--and asking them here is designed to simplify the intake interview for those companies that require one. You do not have to answer any question you don't want to in order to receive services; the counselor will follow up with you if you have not answered a question and she believes it needs to be pursued further.

Completion of this form does not establish you as a client or patient: that occurs with the completion of the Informed Consent Agreement and the first appointment.

This practice does not provide emergency services or crisis consultation to non-clients. If you believe you or or another are in danger, please contact emergency services in your area. These might include: police, sheriff, hospital emergency department, crisis mental health services provided by your local municipality, your primary care physician or practice. If you are having thoughts of self-harm, additional resources may be found at suicidepreventionlifeline.org, or by calling the suicide prevention hotline at 1-800-273-8255 in the US. Crisis text services may be accessed by messaging 741741. In Iowa, additional support may be accessed through the Foundations 2 hotline at 1-800-332-4224.

Thank you for your patience, and we're looking forward to supporting you in achieving your goals.