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You can avoid a mound of paper and save lots of time by using the online form below. Everything is sent directly to your provider.

1. Please complete a CLIENT REGISTRATION FORM (below) for EACH client that will be seen.

2. Please complete a POLICY ACKNOWLEDGMENT form. One document is good for the entire family unless there is a different person responsible for payment.

OR.. If you prefer mounds of paper.

You can manually download, Print, fill these out, and bring them with you at your first appointment.

Policy Only Statements
Policy Statement with Adult Client Intake
Policy Statement with Child Intake and Consent to Treat

Client Registration

New Client information and Medical History

1New Client Registration

2Medical History

3Child Intake Information

4Parent or Guardian Information

5Billing

6Notifications

E-Mail Address Contact
If Child, please enter the parent or guardian email address
Counselor Select
Client Information
Adult or Child
Is the Client an Adult or Child
- Adult
- Child
Client Birthdate
MM slash DD slash YYYY
Client Marital Status
- Single
- Married
- Divorced
- Widowed
- Separated
Name*
First Last
Street Address
Address Line 2
City
- O'Fallon
- Belleville
- Fairview Heights
- Shiloh
- Swansea
- Lebanon
- Scott AFB
- Mascoutah
- Edwardsville
- Granite CIty
- Glen Carbon
- Trenton
- Troy
- Caseyville
- St. Louis
State
- Illinois
- Missouri
Zip Code
Home Phone
Cell Phone
Client SSN
Client Place of Employment
Occupation
Work Phone
Years Married
Spouse Name
Spouse Age
Spouse Place of Employment
Spouse Occupation
Spouse Work Phone
Do You Have Children Living at Home?
- Yes
- No
Please Tell Us their Names and Birth date.s Thanks.
Child Name
Birthdate
MM slash DD slash YYYY
Child Name
Birthdate
MM slash DD slash YYYY
Child Name
Birthdate
MM slash DD slash YYYY
Child Name
Birthdate
MM slash DD slash YYYY

Medical History
Client Physician Info
Please enter the Name, Address, and Phone contact information for the Patients Physician.
Medications
Please list any medications client is currently taking or prescribed
Type of Counseling
- Individual
- Family/Marriage
- Mediation
- Testing
- Court-Ordered
- Psychological Evaluation
- Sports Psychology
- Other
Presenting Problem
State in your own words the reason you are requesting Counseling
Have You Had Previous Mental Health Counseling
- No
- Yes
Type of Counseling (Prev)
- Individual
- Couples
- Family
Previous Mental Health Counseling
Previous Counseling, outpatient treatment, substance abuse treatment or hospitalization - Please include dates and therapists
Expectation of Treatment
What are your outcome expectations

No Child Input Required - Press Next To Continue
Child Intake Information
Child Developmental History
- Destructive Behavior
- Different at an Early Age
- Enursis/Encpresis
- Difficulty Making Friends
- Pregnancy Complications
- Premature Birth
- Difficult Reaction to Starting School
- Significant Trauma
- Significant Loss
Child Developmental History - Leadership
- Leader
- Follower
- Loner
Developmental History - Milestones
Describe any developmental milestones you feel the child did NOT achieve on time
Child Hobbies or Interests
Please tell us what Hobbies, Interests, or Sports your child enjoys
Siblings
Does the Child Client have siblings
- Yes
- No
Sibling Name
Birth Date
MM slash DD slash YYYY
In Same Home
Is the Sibling in the Same Home
- Yes
Sibling Name
Birth Date
MM slash DD slash YYYY
In Same Home
- Yes
Is the Sibling in the Same Home
Sibling Name
Birth Date
MM slash DD slash YYYY
In Same Home
- Yes
Is the Sibling in the Same Home
Child Custody Info
Child Patient - Custody
Who has custody of this child
- Mother and Father (joint)
- Mother (sole)
- Father (Sole)
Parenting Agreement
If you don't have this in Electronic Format, please bring to first appointment
Max. file size: 32 MB.
Child Treatment Authority
Do both parents have equal rights to seek medical or Pyschological treatment for this child?
- Yes
- No
Child Adopted?
- Yes
- No
What Age Adopted

No Child Input Required - Press Next To Continue
Parent or Guardian Information
Parental Information
Which parent(s) or guardian(s) will you enter information for?
- Mother and Father
- Mother
- Father
- Guardian
Mothers Name
First Last
Mother Cell Phone
Mother Home Phone
Mothers Email
Mother Place of Employment
Mothers Occupation
Mother Work Phone
Mother Marital Status
Mothers Lawyer
Enter lawyers name, email, and telephone numbe
Fathers Name
First Last
Fathers Cell Phone
Fathers Home Phone
Fathers Email
Father Place of Employment
Fathers Occupation
Father Work Phone
Father Marital Status
Fathers Lawyer
Enter lawyers name, email, and telephone numbe
Primary Guardian Name
First Last
Guardian Cell Phone
Guardian Home Phone
Guardian Email

Billing Information
This is a Required Entry
Do You Have Insurance?*
- Primary
- Primary and Secondary
- None
Primary Insurance Provider
Primary Insurance Provider*
- Tricare
- Blue Cross Blue Shield
- Aetna
- HealthLink
- CIGNA
- United Healthcare
- MHNet
- OPTUM
- Unicare EAP
- Behavioral Health
Upload Insurance Card (Primary)
If you have an electronic copy of your Insurance Card, you can add it here.
Primary Provider Phone
Primary Provider - Member ID or Account Number
Primary Provider - Sponsor/Subscriber Name
Primary Provider - Sponsor/Subscriber SSN
Primary Subscriber Birthdate (If Different from Patient)
MM slash DD slash YYYY
Secondary Insurance Provider
Secondary Insurance Provider
- Tricare
- Blue Cross Blue Shield
- Aetna
- HealthLink
Upload Insurance Card (Secondary)
If you have an electronic copy of your Insurance Card, you can add it here.
Secondary Provider Phone
Secondary Provider - Member ID or Account Number
Secondary Provider - Sponsor/Subscriber Name
Secondary Provider - Sponsor/Subscriber SSN
Secondary Subscriber Birthdate (If Different from Patient)
MM slash DD slash YYYY

Notifications
Emergency Contact Name

If Child Client, enter a contact if different from Parent already listed.
Emergency Contact Number
Courtesy Call
Would you like a courtesy call to remind you of your appointment?
- Yes
- No
Courtesy Call Number*
Machine/Voicemail
Should we leave a message if a machine or voicemail answers?
- Yes
- No
Email Notification
If you prefer email notification, Please add your preferred email address here
Leave Message*
Can we leave a message if someone else answers the phone?
- No
- Yes
Message Authorization
Can we leave this reminder with anyone else? If only specific people, please enter their name(s) here
Who Can we Thank
If we may say thanks to whoever referred you, Please enter their name, phone number and email address

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