New Client Questionnaire

Let's find the right counselor for you

This takes about 20 to 25 minutes. It helps to have your insurance card(s) nearby. Your answers go only to our clinical team and are kept in your confidential record. You can skip any question you'd rather not answer.

This form isn't monitored for emergencies. If you're in crisis right now, call or text 988, or call 911.

The adult who would attend needs to fill out this form themselves, so their answers stay private. Please share this page's link with them.

Each partner fills out their own form, so please share this page's link with your partner. Neither of you will see the other's answers.

About youAbout you and your child

First, your information as the parent or guardian.

First name

Last name

Name you'd like us to use Optional

Pronouns Optional

Date of birth

County you live in

If you're under 18, a parent or guardian needs to fill out this form for you. Ask them to choose "My child or teen" on the first page.

Phone

Email

Your child

Child's name

Child's date of birth

Grade in school

Your partner

Partner's name

Partner's email

Who would attend? Names, ages, and how each person is related to you

Insurance and scheduling

We do not accept Medicare.

This includes Medicare Advantage plans, which often carry a private insurance company's name. If you have any kind of Medicare, please still list it below so we can check your options.

Please list every health insurance plan you're covered by.

Many people have more than one: through their own job and a spouse's or parent's job, plus Medicaid, TRICARE, or a student plan. A plan left off can mean denied claims and unexpected bills.

That's OK. Check your wallet and any mail from insurance companies, or ask your employer. We'll confirm with you when we call.

You listed Medicare. We can't bill Medicare, so we'll review your coverage and contact you. If we can't see you, we'll give you names of nearby counselors who can.

Photos of your insurance cards Front and back of each card. Optional, but it helps us avoid billing mistakes.

Up to 6 files, 5 MB each.

I've listed every health insurance plan I'm covered by.

Insurance often doesn't cover couples counseling. We'll go over costs with you before your first session so there are no surprises.

For video sessions, you'll need to be in North Carolina during each session.

Preferences

Language you'd prefer for counseling

Do you need any accommodations? Optional. For example, wheelchair access, hearing support, or an interpreter.

Getting started

Who was your counselor, and would you like to see them again?

Who, and how do you know them?

How did you hear about us?

What brings you to counseling?

Answer these about your child.Answer for yourself. Your partner answers separately.There are no wrong answers. Share as much or as little as you like.

What's prompting you to reach out now?

What would you like to be different when counseling is done?

How much is this affecting daily life right now? Work, school, home, sleep

5

0 · Not at all10 · Severely

Which of these apply? Check all that fit, then pick the one that matters most below.

Mood and emotions

Life events

Past experiences

Relationships and family

Thinking and focus

Habits and health

For children and teens

Faith and meaning

Anything else you want the therapist to know? Optional

Which matters most to work on first?

Background

What helped, and what didn't?

Alcohol and drug use

How long have you been in recovery? Optional

Other

Who is requiring it, and why?

How you've been feeling

Over the last 2 weeks, how often have you been bothered by each of these?

Item	Not at all	Several days	More than half the days	Nearly every day

A few more questionsAbout your childAbout your relationshipAbout your family

Has a provider ever given you a mental health diagnosis? Optional. For example: ADHD, PTSD, bipolar disorder.

About when was the most recent stay?

What's happening at home and at school?

Any previous testing or evaluations? Psychological, educational, or medical

How long have you been together?

Who is the counselor?

Are there children in the home? Ages, and whose they are

Who is most concerned, and about whom?

If anyone attending is under 18, we'll ask about custody when we call.

Type of therapy

Another type of therapy? Optional

Safety questions

We ask everyone these questions. They help us make sure you get the right kind of care.We ask every parent these questions about their child and home. Your partner will never see your answers.

In the past month

In the past 3 months

Ever in your life

About when was the most recent attempt? Optional

Right now

Please reach out for help now.

Call or text 988, the Suicide & Crisis Lifeline, any time of day or night. If you or someone else is in immediate danger, call 911.

You can come back and finish this form once you're safe.

Almost done

We review new questionnaires during business hours and will contact you within 2 business days, using only the ways you said were OK.

Payment and your card on file

We know putting a card on file can feel uncomfortable. Your money matters to you, and we take that trust seriously. Here's exactly how it works:

Your card is stored in SimplePractice, our secure records system. We never see your full card number, only the last 4 digits.
To be seen, we need either a card on file or cash paid to your therapist before each visit.
Cards are charged after your visit, only for what you owe for that visit, such as a copay, coinsurance, deductible, or self-pay fee.
A late-cancellation fee, if one applies to you under the cancellation policy below, is also charged to your card on file.
If insurance denies a claim and you owe more than expected, we'll contact you before charging anything.
You'll also receive a card authorization form from SimplePractice to sign.

I understand this payment policy. I authorize Guided Hope Family Counseling to charge my card on file after each visit for services I owe and for any late-cancellation fees under the cancellation policy below, or I will pay cash before each visit.

Type your full name to sign

Cancellation policy

If you can't make an appointment, please let us know at least 24 hours ahead. Cancellations with less notice are handled based on your insurance:

Commercial insurance (for example, insurance through a job): you may be charged a $50 fee. Insurance doesn't pay this fee.
Medicaid: you can't be charged a fee. Instead, late cancellations may limit your ability to schedule future appointments.

I've read the cancellation policy and understand how it applies to me.

Your privacy

Our Notice of Privacy Practices explains how we protect and use your health information. You can read it at guidedhopefc.com/privacy-policy.

I've been given the chance to read the Notice of Privacy Practices. I understand that email and text messages aren't fully secure. I agree to receive scheduling and appointment messages from Guided Hope by the methods I checked earlier. Optional. If you don't check this, we'll contact you by phone only.

I understand this form isn't monitored for emergencies. If I'm in crisis, I'll call or text 988, or call 911.

Let's find the right counselor for you

About youAbout you and your child

Your child

Your partner

Insurance and scheduling

Preferences

Getting started

What brings you to counseling?

Background

Alcohol and drug use

Other

How you've been feeling

A few more questionsAbout your childAbout your relationshipAbout your family

Type of therapy

Safety questions

In the past month

In the past 3 months

Ever in your life

Right now

Almost done

Thank you. Your answers were sent.