Client Therapy Inquiry Form for Aspire Neuropsychological Services
These questions will help our client care coordinator match the best therapist we have for your individual needs. The best possible client-therapist fit is very important to us and something that we take very seriously. After you fill out this questionnaire, we will contact you within 24-48 business hours. Please note that we are a self-pay practice only, however we do accept Tricare insurance. If you have any questions, feel free to call or text us at (925) 885-6070 or email us at info@aspireneuropsych.com
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Email *
Will this appointment be for you or are you making a referral for someone else? *
Who is filling out this form? *
What is your relationship to the patient? *
What is the patient's first and last name? *
What is the patient's date of birth? *
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What is your phone number? *
Is this therapy court-ordered? *
What is the name of your insurance carrier? *
What is your insurance member ID# so we can check your benefits. *
Name and date of birth of primary subscriber  *
Street Address (This is used to verify insurance eligibility) *
City, State, and Zip Code *
THERAPY NEEDS/GOALS
What are you currently struggling with? *
What are your goal(s) for therapy? *
Have you ever experienced thoughts of wanting to hurt/kill yourself or someone else? *
Have you ever had any suicide or homicide attempts? *
PREVIOUS DIAGNOSES/TREATMENT
Have you been previously diagnosed with a mental health condition by a professional? If yes, please list all previous diagnoses *
Is this your first time in therapy? *
Please let us know if there is a specific therapist that  you would like to work with. Therapist bios can be found on our website at www.aspireneuropsych.com 
Is there anything else that you would like us to know?
Please note that our therapists are not crisis counselors. We encourage all clients to call 911 or go to their nearest emergency room if you are having a mental health crisis. Thank you for your time, we will be in touch shortly.
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