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Copy of Service request and benefit checking (for new client screening and current client benefit check only)

Wentworth and Associates, P.C.
11111 Hall Road, Suite 300
Phone (586) 997-3153
Fax (586) 997-4956
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Please only complete this form if you do not yet have a therapist or your assigned therapist directs you to complete it. Please see "intake" packets on our website if you have an assigned therapist and they requested you complete first session forms.
*PLEASE BE AWARE THAT THERE IS VERY LIMITED SERVICES AVAILABLE IN PERSON OR FOR CHILDREN/ADOLESCENTS AND NO PSYCHOLOGICAL TESTING OR COURT ORDERED TREATMENT AT THIS TIME. PLEASE CALL MACOMB FAMILY SERVICES 586-226-3440 OR BIRMINGHAM MAPLE CLINIC 248-646-6659 FOR TREATMENT FOR YOUNG CHILDREN,TESTING,OR COURT ORDERED CASES*
***PLEASE COMPLETE AS MUCH OF THIS FORM AS POSSIBLE AND PUT N/A IN ANY FIELD WHERE YOU ARE UNSURE OF THE ANSWER***
* Today's Date:
* Do you already have an appointment scheduled with one of our therapists?
Name of therapist you are scheduled with (if applicable):
If you were referred to or would like to see a specific therapist, please list their name:
* Who is submitting this form?
If a minor client, please list legal guardians:
Guardian 1
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Relationship:
Email:
Guardian 2
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Relationship:
Email:
Additional client information
Social Security Number
* What phone number should we use? (If different from above)
* May we send texts to the phone number listed?
* E-mail address for correspondence and billing:
* Who is responsible for treatment billing matters?
Language
Cultural Identification/Heritage
Veteran
Gender Identification
Marital Status
If client is in treatment outside the clinic at time of intake, please provide name and phone number of treatment provider
General Status
Disabled   Employed   Refused  
Retired   Senior   Student  
Unemployed - Seeking Employment   Unemployed - Unable to Work   Other:  
GENERAL
* What are the concerns that you would like addressed in treatment?
Have you received assistance from us before?
Are you looking for a specific kind of treatment? If so, please list.
Client preference for therapist:
* Days/times you and/or your spouse or your child is/are available for treatment(please keep in mind evenings and weekends are limited):
* Are you willing to participate in telehealth? (please keep in mind there are a limited amount of in-person therapists)
* Referral Source:
Other Referral Source:
Safety
* Having suicidal/homicidal ideation at time of intake?
Any medical concerns that may affect treatment? If yes, please list.
* Any history of substance abuse? If so, what and when?    Please describe your substance use.
Any legal issues that may effect treatment? If so, please list.
Insurance and Financial Information
* Insured?    Does the patient have insurance?
* Insurance Name:
* Insurance Address:
* Insurance City, State and ZIP:
* Insurance Phone:
Insurance Effective Date:
* Policy Number:
* Group Number:
* Subscriber name:
* Subscriber date of birth:
Medicare Number:
Medicaid Number:
Additional comments:
Form Updates
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