Patient Details and Screening Form

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Insurance Lookup

(FOR OFFICE USE ONLY)

Today's Date

Client's Name

First

Last

(Legal name)

Client's Date of Birth

Client's Age

Please select sex

For insurance purposes

Gender Identity

(optional)

Preferred pronouns

(optional)

Client's Address

Address Line 1

Address Line 2

City

State

Zip Code

I'm filling this request out for

Myself
My spouse/partner
My child
Other

Client Marital status

Child's Parents' Marital status

Important Message:

When a minor is brought to our practice for therapy and the parents are not married, we will require the written consent of both custodial parents in order to provide services. In addition, in cases of divided custody, we will require a copy of the court's order regarding custody arrangements.

We encourage you to review our policies when working with clients under 18.

Below, we will ask for your name as well as the name and contact information of the child's other custodial parent for our files.

What is your relationship to the prospective client?

Client's Phone

Best number for the therapist to reach the client directly once therapy begins, for scheduling or other matters.

Client's Email

To be used for notifications from our offices regarding Patient Portal instructions, statements and forms to fill out.

Your Name

First

Last

Person filling out this form

Phone

Best number to reach you, and to receive texts from our office concerning scheduling or billing.

Your Phone

If we have any questions about the information on this form.

Your Email

For confirmation of receipt of this form and if we have any questions.

Your Email

(Parent/Guardian) For confirmation of receipt of this form, as well as notifications from our offices regarding Patient Portal instructions, financial statements and any forms to fill out. In the case of a minor, our offices will coordinate all initial scheduling with the parent.

Name of child's other custodial parent

First

Last

Phone number of child's other custodial parent

How can we help?

Most answers are required so we can better understand how best to assist you.

What type of services are you looking for?

Were you referred by any practitioner specifically for Biofeedback services?

Yes
No

Name of practitioner who suggested Biofeedback

(All communication with outside practitioners will require client's prior written consent)

Please elaborate on your interest in our Biofeedback services

Which group(s) were you interested in attending or learning more about?

Betrayal Trauma Group (Women)
Men's Anxiety Group (in-person)
Virtual DBT Groups (All adults)
DBT Skills Group (in-person, Women)
Online Depression Support Group (All adults)
Online Anxiety Support Group (All adults)

Please check all the items below that describe your situation:

Have you ever had previous therapy/counseling of any kind?

Yes, once
Yes, a few times
No

Has the client ever had previous therapy/counseling of any kind?

Yes, once
Yes, a few times
No

Is your child currently attending school?

Yes, regularly
They skip school when symptoms are bad
Refusing to go to school
Is not allowed back at school without a psychiatric evaluation

Important Message:

Our practice conducts therapy and counseling. Typically return-to-school requires an evaluation by an MD or Psychiatric APN. Hi Focus Centers (877) 561-9633 has several locations in New Jersey that can quickly provide this kind of evaluation.

Are you/Is the client prescribed medication for any of the above conditions?

Yes
No
I'm hoping you can prescribe or re-prescribe medications

Important Message:

Our practice consists only of psychotherapists/psychologists, counselors and therapy specialists. We do not prescribe medication at all. Please consult your provider directory for a list of psychiatrists or psychiatric nurse practitioners in your area.

or Message: drive

Are there any current restraining orders in place within in the couple/family?

Yes
No

Is there any current DCP&P involvement in your family?

Yes
No

Are you or your family member being required by an outside party to seek treatment at this time?

Yes
No

How compliant is the client with taking this medication as prescribed?

Perfectly	Somewhat compliant	Not very compliant	Has stopped taking it on one's own
PerfectlyPlease rate Perfectly	Somewhat compliantPlease rate Somewhat compliant	Not very compliantPlease rate Not very compliant	Has stopped taking it on one's ownPlease rate Has stopped taking it on one's own

Does the client currently have trouble with drugs or alcohol?

Yes
No

Please choose which best describes the drug/alcohol use:

Significant difficulties with drugs or alcohol, and I/we are simultaneously looking for help with it
Currently in drug/alcohol treatment
It's a problem together with the psychological issues; I don't know which is worse
Would like treatment from your offices for drug/alcohol problems

Important Message:

While some substance use or overreliance on alcohol can occur in the context of emotional and psychological struggles, if the substance or alcohol use has become your predominant problem, you will need to seek services at a specialized drug/alcohol treatment center, such as Hi Focus or Gen Psych in New Jersey. Our practice does not specialize in drug or alcohol abuse treatment.

Are you or the client currently involved in any legal proceedings?

Yes
No

(Sensitive questions follow)

Are you concerned about your or anyone else's safety in your home?

Yes
No

Have you ever had thoughts that you would be better off not living anymore?

Yes, currently
Yes, but only in the past
No

Has the client ever had thoughts that they would be better off not living anymore?

Yes, currently
Yes, but only in the past
No

Important Message:

Unfortunately, our practice is not emergency services or urgent care. If you or your family member are currently experiencing these thoughts and feelings, call an urgent care center right away: Mobile Response 877-652-7624 will usually be able to send a team out to you within an hour. The suicide and crisis helpline is simply 988. Confidential urgent helpline for teens: 888-222-2228. And dialing 911 or just going to your nearest ER is always a safe option.

Have you ever had thoughts of harming yourself?

Yes, currently
Yes, but only in the past
No

Has the client ever had thoughts of harming themselves?

Yes, currently
Yes, but only in the past
No

Important Message:

Unfortunately, our practice is not emergency services or urgent care. If you or your family member are currently experiencing these thoughts and feelings, call an urgent care center right away: Mobile Response 877-652-7624 will usually be able to send a team out to you within an hour. The suicide and crisis helpline is simply 988. Confidential urgent helpline for teens: 888-222-2228. And dialing 911 or just going to your nearest ER is always a safe option.

Have you ever been hospitalized for psychiatric reasons or substance abuse?

Currently in inpatient or intensive outpatient treatment (IOP), looking for therapy once discharged
Yes, discharged within the past 30 days
Within the past year
More than a year ago
More than 5 years ago
No

Has the client ever been hospitalized for psychiatric reasons or substance abuse?

Currently in inpatient or intensive outpatient treatment (IOP), looking for therapy once discharged
Yes, discharged within the past 30 days
Within the past year
More than a year ago
More than 5 years ago
No

Important message

We will require discharge paperwork in order to proceed with our intake process. With written consent, your caseworker can also reach out to us.

Are you seeking to "follow" your clinician from another practice who now works at IPG?

No
Yes

In addition to what you wrote on your initial form, is there anything else you might add for us to get a better picture of your current request for therapy?

Please clarify once again which in-person offices you can drive to:

Click here to see details of our office locations.

Being that you selected Telehealth, which statement below describes your situation:

I'm too far to drive to your offices, but I will be in New Jersey for my sessions
I prefer the convenience of Telehealth if possible, but I'll be in New Jersey for sessions
I travel a lot and may be out of state or the country for some of my sessions
I will soon be going out of state/the country for school or work

Important Message

IPG providers are only licensed to practice in New Jersey. By law, clients must be physically located in New Jersey during their Telehealth visits. We will not be able to provide counseling services when clients are out of state.

Availability (please read)

As you may know, evening appointments with therapists are hard to find because everyone wants them! We provide you several options below, but keep in mind that if you can make yourself available during the daytime for your ongoing weekly appointments, we will have more flexibility with which therapist you will be assigned and we'll be able to get you an appointment soonest.

What is your availability for weekly therapy sessions:

I can make myself availble for appointments during the day
I, or my child, cannot do daytime appointments at all and require an evening time
My availability is complicated (please explain in the box that appears below)

Paragraph Text

Emergency Contact

If you have a psychiatric emergency and we need to get in touch with and inform a person who will support you.

Phone number

How did you first hear about us?

Payment/Insurance Information

We ask for your detailed information here so that we can quickly respond to your request regarding our participation in your plan's network

How will you be paying for treatment?

Client's relationship to primary insurance holder

Self
Spouse/Partner
Child
Other

Name of primary insurance holder

Date of birth of primary insurance holder

Subscriber/Member ID#

Primary Insurance Company

Please upload a copy/pic of your insurance card (if you are unable to upload a picture of your cards, check the box below)

Check if you are unable to upload your insurance cards. Our office may reach out to you for other ways to submit your card

Front of card

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

.PNG, .JPG, .JPEG, .DOC, or .PDF Format Only

Back of card

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

.PNG, .JPG, .JPEG, .DOC, or .PDF Format Only

Do you have secondary insurance coverage?

Client's relationship to secondary insurance holder

Self
Spouse/Partner
Child
Other

Name of secondary insurance holder

Date of birth of secondary insurance holder

Subscriber/Member ID#

Secondary Insurance Company

Please upload a copy/pic of your insurance card (front)

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

.PNG, .JPG, .DOC, or .PDF Format Only

Please upload a copy/pic of your insurance card (back)

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

.PNG, .JPG, .DOC, or .PDF Format Only

If you were unable to upload a picture of your insurance cards, we may reach out to you to confirm we have your correct insurance information.

Please click Submit below and our team will review your information and get back to you within 1-2 business days with your assigned therapist or if we have any further questions.

New Patient Details and Brief Screening Form

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Availability (please read)

Payment/Insurance Information

Initial Appointment Request

Patient Portal Login

Update your Information

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Group Therapy

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Patient Portal Login

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Group Therapy

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