Client Information Form

Client Information
NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under the age of 18, the parent or guardian must complete and sign this form.
Client's legal Name*

First NameLast Name
Client's preferred name*
Client's preferred pronouns
Date of Birth*

MonthDayYear
Date of Birth
Today's Date*

MonthDayYear
Today's date
Age*
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
What services are you looking for within Serenity? (check all that apply)

Individual CounselingPsychiatry-Medication ManagementCouples CounselingFamily CounselingGroup TherapyTelehealth (Note: all therapists can see clients via telehealth)
How do you prefer Serenity-BHS contact you? (You may select more than one option.)

TextPhone/CellEmail
Relationship to Client?*

SelfSpouseLegal ParentGrandparentFoster ParentStep ParentNo relation - Referring EntityOther
Are you the legal custodial parent for this minor person?
Referring Entities - please fill out the following information
What is the source of this referral (where do you work)? *
Referring Entity - full name*

First NameLast Name
Referring Entity - email*
example@example.com
Referring Entity - Phone Number*

Area CodePhone Number
Referring Entity - additional comments
Please upload custodial paperwork.

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Full name of legal custodial/guardian:

First NameLast Name
Client demographics
Race/Ethnicity*
Sexual Orientation*
Gender*

MaleFemale
Gender Identity*
Emergency Contact*

NamePhone Number
Primary Contact Phone Number

Area CodePhone Number
Is it okay to leave a message

YesNo
Serenity Location*
Medication Management*
Columbus Therapists*
Dublin Therapists*
Westerville Therapists*
Westerville/Blendon Woods Therapists*
Deaf Services Therapists*
Serenity Therapists*
Cornerstone-Annex Academy Therapists*
Appointment Time Preference (select all that apply):*

MorningsAfternoonsEveningsSaturdaysAnytime
OLD - only one selection allowed....Appointment Time Preferences:*

MorningsAfternoonsEveningsSaturdaysAnytime
Who is the counseling for?*

Child, under the age of 12Adolescent, ages 13-17Young Adult, ages 18-29Adult, ages 30-64Senior, ages 65 and over
Presenting Problem
What are the 2-3 primary reasons you are seeking counseling/therapy?*
How long ago did you begin to be troubled by this problem?*
Have you been hospitalized or completed any other treatment programs in the last 3 months?
List three (3) goals you would like to accomplish by attending counseling:*
Are you interested in participating in group therapy?:

YesPerhaps in the futureNo
What is this in relation to? (select all that apply)*

ADD/ADHDAddictive DisordersAdjustment DisordersAdolescent Behavioral DisordersAdoption IssuesAdult ADDAIDS/HIVAnger ManagementAnxiety, Panic DisorderAttachment DisorderAutism, Asperger'sBipolarChemical Dependency, Drug AbuseChristian, SpiritualCultural IssuesCodependencyCo-occuring DisordersCo-parentingCognitive DisorderConcussionCriminal OffendersDementia DisordersDevelopmental DisordersDisruptive DisordersDissociative DisordersDivorce, SeparationDomestic AbuseDomestic ViolenceDual DiagnosisDepressionDisabledEating DisordersFamily DysfunctionGamblingGay, Lesbian, BisexualGender Identity IssuesGrief, Loss, BereavementHead TraumaHoardingImpulse DisordersInfertilityLearning DisabilityLife TransitionsMarital and Premarital IssuesMedical Illness, Chronic IllnessMen's IssuesMood DisordersObesityObsessive Compulsive DisorderOppositional Defiant DisorderOrganic Mental DisorderParenting IssuesParental AlienationPersonality DisordersPregnancy, Post-partum DisorderPTSDPanic DisorderPhobiasPhysical AbuseRelationship IssuesReactive Attachment DisorderRelapse PreventionSchool IssuesSexual AddictionSexual Physical AbuseSexual Physical Abuse (children)Sexual DisordersSexual DysfunctionSexual Abuse, IncestSexual OffenderSleep DisorderSports PerformanceStep-blended FamiliesStress ManagementSelf InjurySubstance AbuseSuicidal IdeationTransgenderTraumaTraumatic Brain InjuryWeight LossWomen's IssuesWork-Related IssuesOther
How would you like to pay for your services (check all that apply)?

Personal Health InsuranceEmployee Assistance Program (EAP)MedicaidMedicareCornerstone AcademyPrivate Pay
What primary insurance do you have? (ex: Anthem, Humana, Cigna, etc)*
What secondary insurance do you have? (ex: Anthem, Humana, Cigna, etc) If you do not have secondary insurance, please write NONE.
Primary Insured Member Information:
Private Pay

Yes (I agree to pay for each session. No insurance information will be provided to Serenity for billing purposes.)No (Please bill my insurance.)
Employee Assistance Program (EAP)

YesNo
Additional EAP Information
Cornerstone Academy

YesNo
Primary Health Insurance

N/AAetnaAetna MedicaidAnthemBuckeye Health Ambetter/MarketplaceCaresourceCignaDennison UniversityHumanaOhio HealthOptima - Ohio HealthOptum - UHCUHC MedicaidTricareMedicaidMedicareMedical MutualUMROther
Member ID:*
Group ID: *
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Secondary Health Insurance

N/AAetnaAetna MedicaidAnthemBuckeye Health Ambetter/MarketplaceCaresourceCignaHumanaMedical MutualMedicaidMedicareOhio HealthOptima - Ohio HealthOptum - UHCUHC MedicaidTricareUMROther
Member ID: *
Group ID:*
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
I Authorize Serenity-BHS to check benefits on behalf of the client seeking counseling.
Provide Copy of Insurance Card (front and back are needed)

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Do you Authorize?*

YesNo
Client's Name*
Additional Information
Who referred you to us?*

PsychologyTodayFamily DoctorCornerstone AcademyHealth InsuranceGoogleYelpFriendOther
Are you related to a Serenity staff member?

YesNo
If yes, who?
Please verify that you are human*
Should be Empty: