EmailMe Form - Inquiry Form (Website)

Potential client’s Legal name: *

First Last

Potential client’s DOB: *

MM / DD / YYYY

Who is completing this form?

Potential client

Parent/Guardian

Referring Worker

Other

If a referring worker is completing this form, please include name, agency and contact information:

Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email address: *

Contact number: *

### - ### - ####

Is it OK if the therapist corresponds with you via email: *

Yes

No

Do you have immediate family members who work at LFCS?: *

Yes

No

What is the primary reason for seeking services?: *

Is the potential client enrolled in therapy services elsewhere?

If yes, please confirm if you are seeking services for the same concerns, different concerns, or are seeking to transition to a new therapist.

Are there any safety concerns (self-harm, harm to others, suicidal ideations, homicidal ideations)?: *

Yes

No

Please explain safety concerns

Do you have specific days or times needed for the initial session?: *

Do you have a preference for in person or virtual (video meeting over Microsoft Teams) sessions?: *

Yes, In-person

Yes, virtually

Open to either in-person or virtual

Would you be open to the possibility of working with a graduate level intern who is closely supervised by a licensed therapist?: *

Yes

No

How did you learn about LFCS?: *

Do you have the ability to consent to services? *

Yes

No

Parent/Guardian (1) Name

First Last

Parent/Guardian (1) Phone

### - ### - ####

Parent/Guardian (1) Email

Parent/Guardian (2) Name

First Last

Parent/Guardian (2) Phone

### - ### - ####

Parent/Guardian (2) Email

Emergency contact (optional):

Are you interested in learning about our psychiatry services?

Yes

No

The following questions are for demographic purposes. These are optional.

What is the race of the client?

What is the household income of the client (or parent/guardian):