Get Tn Ebenezer Counseling Services Adult Intake Form Pkg 2020-2025

Completing the TN Ebenezer Counseling Services Adult Intake Form Pkg online is an important step in accessing mental health services. This guide provides clear and user-friendly instructions for successfully filling out each section of the form to ensure your experience is smooth and efficient.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin with the date section. Enter the current date, ensuring it is formatted correctly, as this will help track your intake information.
3. In the email address field, provide a valid email to facilitate communication with the counseling center.
4. Fill in your full legal name in the designated field. Make sure it matches your identification documents.
5. Enter your complete address, including your city, state, and zip code.
6. Provide your home and cell phone numbers for contact purposes. If you prefer, indicate if the office may contact you at your workplace.
7. Input your Social Security number and date of birth for identification and billing reasons.
8. Indicate your age, sex, and marital status to provide context for your counseling needs.
9. Specify who you currently live with from the given options, which helps the counselor understand your living situation.
10. If applicable, provide your spouse’s name and details about your marital history, such as years married and previous marriages.
11. State your occupation and employer, along with your weekly work hours. If you are a student, include your educational institution and whether you are full-time or part-time.
12. Identify who is responsible for bill payments and their relation to you, along with their address if it differs from yours.
13. Specify whether you will use insurance for payments. Fill out the insurance company details and provide your policyholder’s information.
14. Review the education section and check all relevant boxes, indicating all schools attended.
15. Indicate your church or denomination affiliation if applicable.
16. In the health section, describe any physical problems requiring medication or care and list the medications you currently use.
17. Answer the questions regarding medical treatment, past therapy, or hospitalization experiences.
18. Identify and check all problem areas that concern you. Use comments for further clarification if needed.
19. Provide a brief description of the main problem prompting your therapy request and any additional details you want your therapist to know.
20. Sign and date the form to confirm your agreement with the policies and your informed consent for treatment.
21. Once all fields are completed, save your changes. You can choose to download, print, or share the form as required.

Start filling out your TN Ebenezer Counseling Services Adult Intake Form Pkg online today!