Angie Simonton, LCSW
Please complete the following form and return via email at email@example.com
Referred by: ________________________________________
Name of Client: ______________________________________
Date of Birth: ________________________
If the Client is a minor (under 18), please list BOTH Parents’ names and Work/Home phone numbers, and also list Step parent(s)’ names and contact information:
In order for a therapist to work with a minor child, legal guardians are required to give verbal and written consent of counseling. Also a copy of current custody paperwork is required (if one is in place).
Marital Status of Client: (circle) Single, Married, Life-Partner, Divorced, Separated Widow/er, Living with a partner.
Email address of Client or Guardian:
Insurance Clients: Name of Client’s Insurance Plan and Mental Health contact information :____________________________________________________________________________
Whose name and date of birth is the insurance plan in:
Insurance member number: ________________________________________
Insurance Group number: ________________________________________
Please Attach An Image of the front and back of the Insurance card for verification of Benefits.
Is the client attending school? If so which school and what grade?
Does the client have a 504 or IEP plan in place? Yes____. No______
Is the client in special education classes or gifted classes? Yes_______ No_____
Is the client employed, if so where? __________________________________________________________________________________________
Phone Numbers of Client or Legal Guardian(s): Home______________________ Cell___________________Work________________
Is it ok to leave messages on voicemail?
Name/Phone number of Emergency Contact:
By completing this I am giving Ms. Simonton the ability to contact the above person(s) in an Emergency Situation. Please initial for Agreement __________________
Pharmacy used and phone number:_________________________________________________________________________________
Medications and Prescribing MD:
Reasons the client is seeking therapy services at this time? Please be as specific as possible. If you require more space feel free to write on an additional page.
Has the client been diagnosed with a mental health issue? If so, what is the diagnosis(es), who diagnosed, and when?
Is the Client working with a therapist at present or has the client been in therapy in the past?
Has the client been psychiatrically hospitalized before? If so where and when?
I am willing to sign a release of information for Ms. Simonton to speak with my Primary Care Physician, Other Medical Providers, and School (if needed). Please initial agreement________________
I understand that Ms. Simonton does not provide: couples counseling, divorce mediation, custody mediation, parent coordination services, nor is she a court appointed expert. However in the event that Ms. Simonton is called to court to for a case you are involved in, she charges 250.00 an hour. Please initial your agreement and understanding: ____________________
I have or will review Ms. Simonton’s Information on her website, http://www.angiesimontonlcsw.org under the pages “Important Information” and “Being Honest about Therapy.” Initial for agreement _________________
I understand that Ms. Simonton uses a medical biller. I am agreeable to her sharing my information with the billing agency for collection purposes. If I am under Ms. Simonton’s care I will sign a release of information for this, unless I am a Private Pay Client. Initial for agreement____________________
I understand that the completion of this form does not guarantee treatment under the care of Angie Simonton, LCSW. But it is instead a request for the most appropriate treatment. Please sign and date. Thank you.
Signature and date of completion
(Updated version 3/25/18)