Angie Simonton LCSW-BACS

Please complete the following form and return via email at angie@angiesimontonlcsw.org

Date: ________________

Referred by: ________________________________________

Name of Client: ______________________________________

Date of Birth: ________________________

Age_____________

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.

Client’s Address:

City _______________________

Zip code____________________

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?

YES________ NO_________

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. Initial for agreement____________________

I understand that if Ms. Simonton provides treatment to me and I do not pay for the services rendered, then she will make several attempts to have the funds paid in a timely manner. However if that does not occur, then I understand that Ms. Simonton will send my unpaid balance to a billing collection agency. Initial for Agreement _______________

I understand that the completion of this form does not guarantee treatment under the care of Angie Simonton LCSW-BACS. But it is instead a request for the most appropriate treatment. Please sign and date. Thank you so much!!!



Signature and date of completion

(Updated version 1/29/2018)