ANNE MILLIGAN, LCSW COUNSELING THERAPY INTAKE QUESTIONNAIRE
 
 
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PLEASE FILL OUT THE FOLLOWING INTAKE QUESTIONNAIRE AND PRESS "SUBMIT" AT THE BOTTOM OF THE PAGE. PLEASE NOTE THAT ALL INFORMATION EXCHANGED ON THIS WEBSITE IS COMPLETELY CONFIDENTIAL. TO CONTACT US DIRECTLY, CALL 502-423-0220 OR CLICK HERE TO SEND AN E-MAIL.





WHAT IS THE CLIENT'S NAME AND DATE OF BIRTH? IF YOU ARE NOT THE CLIENT, PLEASE ALSO PUT IN YOUR NAME AND RELATIONSHIP TO THE CLIENT.:
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WHAT IS YOUR HOME ADDRESS?:
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WHAT IS YOUR HOME PHONE? PUT "NONE" IF NOT APPLICABLE.: *
YOUR CELL PHONE NUMBER (INCLUDING AREA CODE)? PUT "NONE" IF NOT APPLICABLE.: *
PLEASE PUT YOUR CURRENT STATUS HERE:*
WHAT IS THE NAME OF YOUR INSURANCE COMPANY? (INDICATE "NO INSURANCE" IF YOU ARE NOT USING INSURANCE.: *
IF YOU ARE USING INSURANCE, WHAT IS THE FULL NAME AND DATE OF BIRTH OF THE INSURED PERSON? HOW IS THE INSURED PERSON RELATED TO THE CLIENT?:
PLEASE ENTER YOUR INSURANCE MEMBER ID # OFF THE FRONT OF THE CARD. PLEASE ALSO ENTER THE INSURANCE CUSTOMER SERVICE NUMBER FROM THE BACK OF THE CARD.:
PLEASE ENTER THE EMPLOYER OF THE INSURED PERSON:
SOME INSURANCES REQUIRE PRE-AUTHORIZATION IN ORDER TO PAY FOR THERAPY. IF YOU HAVE RECEIVED AN AUTHORIZATION NUMBER, PLEASE ENTER IT HERE.:
DO YOU HAVE AN OUTSTANDING DEDUCTIBLE ASSOCIATED WITH THIS INSURANCE? (CALL CUSTOMER SERVICE NUMBER ON THE BACK OF YOUR INSURANCE CARD FOR THIS INFORMATION). :
PLEASE CLARIFY THE PROBLEM OR NEED THAT MOST RESEMBLES WHAT YOU ARE LOOKING FOR IN THERAPY. PLEASE STATE YOUR GOALS FOR THERAPY AS CLEARLY AS POSSIBLE.:
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WHAT IS YOUR E-MAIL ADDRESS? :
PLEASE LIST ANY PLACE/S THAT YOU DO NOT WANT TO BE CONTACTED BY THE OFFICE OF ANNE MILLIGAN. PLEASE PUT "OKAY" IN THE BOX IF YOU AUTHORIZE US TO COMMUNICATE WITH YOU BY EMAIL AND PHONE AND THERE ARE NO OTHER PLACES YOU DO NOT WANT TO BE CALLED OR E-MAILED.:
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I HAVE READ AND UNDERSTOOD THAT ALL OF THIS INFORMATION IS HELD TO THE STRICTEST PRACTICES OF CONFIDENTIALITY AND WILL NOT BE SHARED WITH ANYONE WITHOUT MY WRITTEN PERMISSION. (PLEASE PUT YOUR NAME IN THE BOX. THIS WILL SERVE AS YOUR SIGNATURE).: *



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