Lighthouse Clinical Social Work

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Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Address of client:

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Pronouns

She/her He/Him They/them Other

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Depression Grief Substance use Trauma Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

Referral source

Enter how you heard of this provider or office? (friend, primary physician, psychiatrist, health insurance directory, Lighthouse Clinical Social Work website, Peaceful Pathways website, therapist directory, hospital, another mental health provider, etc.)

Driver's license upload

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Billing & Payment

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Insurance details

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Insurance card upload

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Client Preferences

Is there anything that the practitioner needs to know?

For example: special circumstances requiring accommodations related to mobility, hearing, vision, cognitive functioning, etc., what you'd like to focus on, insurance or payment questions, etc.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.