Date: _______________
Sparkman Counseling Services
Virginia Sparkman
Client Intake Information
Client Name: __________________________________________________________________
(First)
(MI)
(Last)
Address: ______________________________________________________________________
City/State/Zip Code: ____________________________________________________________
Home Phone #: __________________________
Circle: Male / Female
Work Phone #: __________________________
Age: ___________ DOB: ______________
Cell Phone #: ___________________________
SS#: _______________________________
Present Relationship Status (circle): Married Living Together Divorced Widowed
Separated Engaged Boyfriend/Girlfriend No Significant Relationship
Present Employment Status (circle): Full Time Part Time Disabled Retired
Unemployed
Name of Employer: _____________________________________________________________
How did you hear about Sparkman Counseling Services?
______________________________________________________________________________
Emergency Contact Name: ______________________________________________________
Relation to Client: ______________________
Phone #: ____________________________
PRIMARY INSURANCE
Insurance Name: _______________________________________________________________
Insurance ID #: _________________________
Insurance Group #: ____________________
Insurance Telephone #: __________________________________________________________
Policy Holder’s Name: __________________________________________________________
(First)
(MI)
(Last)
Policy Holder’s DOB: ____________________
Policy Holder’s SS#: __________________
Relation to Client: _______________________
Policy Holder’s Phone #: _______________
Policy Holder’s Address: _________________________________________________________
City/State/Zip Code: ____________________________________________________________
Policy Holder’s Employer: ____________________________
Work #: ________________
SECONDARY INSURANCE
__ Not Applicable (I do not have any other insurance coverage)
Insurance Name: _______________________________________________________________
Insurance ID #: _________________________
Insurance Group #: ____________________
Insurance Telephone #: __________________________________________________________
Policy Holder’s Name: __________________________________________________________
(First)
(MI)
(Last)
Policy Holder’s DOB: ____________________
Policy Holder’s SS#: __________________
Relation to Client: _______________________
Policy Holder’s Phone #: _______________
Policy Holder’s Address: _________________________________________________________
City/State/Zip Code: ____________________________________________________________
Policy Holder’s Employer: ____________________________
Work #: ________________
Sparkman Counseling Services
Virginia Sparkman
Date:
BENEFIT REQUEST
Provider:
Name:
DOB:
Insurance:
Contract #:
Effective Date:
Phone #:
In Network
Out of Network
Copay:
Coinsurance:
Deductible:
# of Visits a Year:
Authorization:
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MICHIGAN ENROLLS (Medicaid Verification): 1-800-975-7630
Verified by: ________________________________________
Date: ________________
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Sparkman Counseling Services
Virginia Sparkman
Client Intake Information
Client Name: _____________________________________________ Date: _______________
CURRENT SYMPTOM CHECKLIST (rate intensity of symptoms currently present)
Check all that apply
None- (N) This symptom not present at time Mild- (Mi) Impacts quality of life, but no significant impairment of
day-to-day functioning Moderate- (Mo) Significant impact on quality of life and/or day-to-day functioning Severe(S) Profound impact on quality of life and/or day-to-day functioning
N Mi
Depressed mood
Appetite disturbance
Sleep disturbances
Elimination disturbance
Fatigue/low energy
Psychomotor retardation
Poor concentration
Poor grooming
Mood swings
Agitation
Emotionality
Irritability
Generalized anxiety
Panic attacks
Phobias
Obsessions/compulsions
Bingeing/purging
Laxative/diuretic abuse
Anorexia
Paranoid ideation
Circumstantial symptoms
Loose association
Delusions
hallucinations
Mo
S
N Mi
Mo
S
Aggressive behaviors
Conduct problems
Oppositional behavior
Sexual dysfunction
Grief
Hopelessness
Social isolation
Worthlessness
Guilt
Elevated mood
Hyperactivity
Dissociative states
Somatic complaints
Self-mutilation
Significant weight gain
Significant weight loss
Concomitant medical condition
Emotional trauma victim
Physical trauma victim
Sexual trauma victim
Emotional trauma perpetrator
Physical trauma perpetrator
Sexual trauma perpetrator
Substance abuse
OTHER:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________