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Solace House Intake Form
Please fill out to indicate interest in services. You will hear from us within three business days.
*This form should only be filled out by the interested party
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Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Client's Name
*
Your answer
What service modality are you interested in
*
Choose
Individual Sessions - Grief Related
Individual Sessions - Trauma Related
Group Sessions
Family Sessions - Trauma or Grief Related
Both Individual and Group Sessions
Referrals
Not Sure
Client's Date of Birth
*
MM
/
DD
/
YYYY
Client's Race/Ethnicity
*
Your answer
Client's Gender Identity
*
Your answer
What was your sex assigned at birth?
*
Male
Female
Prefer not to say
Unknown
Other:
Parent/Guardian's Name (if applicable)
Your answer
Parent/Guardian's Date of Birth (if applicable)
MM
/
DD
/
YYYY
Home Address
Your answer
County (or Zipcode)
*
Your answer
Email
*
Your answer
Was your loved one served by Kansas City Hospice in the last year?
*
Yes
No
Other:
Best contact number
*
Your answer
Emergency Contact Name & Relationship
*
Your answer
Emergency Contact Number
*
Your answer
Do you have insurance?
Yes
No
Other:
Clear selection
If yes to insurance, what carrier?
Your answer
Social Security Number (for insurance purposes if applicable)
Your answer
List other family members in the household: Name, Age, and Relationship
Your answer
What is your combined household income? (for grant/sliding scale purposes)
Your answer
Briefly describe why you are seeking our services
*
Your answer
If you are seeking services for grief what is the cause of death?
Choose
Illness
Accident
Substance Use/Overdose
Suicide
Homicide
Unknown
Name of the Deceased 1 (if applicable)
Your answer
Date of Death 1 (if applicable)
Your answer
Name of the Deceased 2 (if applicable)
Your answer
Date of Death 2 (if applicable)
Your answer
What are your strengths?
Your answer
Describe your support system
Your answer
Have you ever had inpatient or outpatient treatment for emotional or mental health concerns in the past?
Yes
No
Other:
Clear selection
If so then where and when were services?
Your answer
Please check any of these that apply to you.
frequent mood swings
nervousness/anxiety
difficulty in concentration or memory
feelings of hopelessness
excessive fear and/or phobias
thoughts of suicide
racing thoughts
thoughts of harming others
behavior issues
poor impulse control
attempts at suicide
difficulty managing anger
panic attacks
changes in appetite or weight
depressed mood
frequent feelings of guilt
seeing things other people don't
cutting/hurting self
problems responding to discipline
history of physical/sexual abuse
bed wetting
financial stress
difficulty at work
family conflict or change in family relationships
previous or current drug and alcohol problems
legal issues
separation anxiety
Option 28
List any medical or physical issues you would like your therapist to be aware of.
Your answer
Do you have a regular medical provider?
Yes
No
Other:
Clear selection
List any prescription and over the counter drugs and supplements you use.
Your answer
Please add anything important that you want your therapist to know (i.e. past or recent trauma, gender identity, your pronouns, sexual orientation, multiple losses, cultural identity information)
Your answer
How did you hear about us?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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