Corporate & Self-Referral Demographic Form:               

MHFR Telehealth Services:

Please complete this form and we will respond to you as soon as we can.  Write N/A if it is not applicable to you.

Counseling or Psychotherapy is either self-pay or corporate account. We are no longer providing free services. 

Thank you for contacting MHFR Telehealth Services.


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Email *
Referral Source
Name *
Home Address *
Cell Phone *
Occupation/Job *
Date of Birth *
MM
/
DD
/
YYYY
What is your Age (if you are a minor, we need your guardian or parental consent). *
Who referred you to us? (Name of your Company or the person) *
How could we contact you? (What's App, email, text, phone, etc.) please write the information below. *
Relationship Status *
Gender Identity *
Do you prefer a male or female provider? *
Mental Health History
Have you been in counseling/therapy before? *
Have you been diagnosed before? If yes, with what diagnosis? *
Are you taking any medications? *
If yes, What medication are you taking? *
Alcohol & Drug History - past & present *
Childhood Trauma History - Physical, Sexual, or emotional? *
Reason/s for seeking counseling? *
Emergency Contact - write their name and phone number. *
Who is responsible for the Professional or Consultation Fees? (Pls. write their name and contact information [company name]) *
If you are a minor, below 18 y.o., we need your guardian/parental name and number.  Write N/A if not applicable. *
Is this a Corporate Account?  Pls. write the name of the company that will cover the consultation fees. We need to have a contract with them. *
Informed Consent
Before you go, you must complete our informed consent to start your services with MHFR before clicking submit. 

Corporate Client: The link is located here - INFORMED CONSENT.

I declare that the above information is true and accurate, and my company refers me or I self-refer.   *
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