Group Therapy Quick Get to Know You

Group Intake Information

After you fill out this form a therapist will call you for a quick 15 minute consult before setting up an intake with you. Everything you discuss on this form, or in the future with a Whole Connection therapist, will be kept confidential and stored only in our locked locations. Your privacy is important to us, but we are also trying to make sure that our services are a good fit for you. Please be aware when filling out the form, that we are mandatory reporters for child and elder (70+) abuse and neglect as well for active suicidal or homicidal plans. Please know we are on the second floor and there is no elevator, if going up stairs would be difficult please let us know. We will reach back out to you in 24-48 hours. We start with a 10-15 minute phone intake with one of our clinicians. If you are in a crisis please go to http://coloradocrisisservices.org/, or call 1-844-493-8255

Name

If you are using insurance, Please put your legal and preferred name too if you have one you wish for us to use.

First Name

Last Name

Date of Birth

YYYY

Best phone number to reach you at

(###)

###

####

Can we leave you a voicemail or email message on this number and email address?

Yes to Email

Yes to Voicemail

How would you like to pay for therapy?

If you are using insurance, please put in your insurance number below

Which group are you interested in?

What's bringing you in for group therapy at this time?

Is there anything else you would like us to know?

This could be a recent event or how you might identify

How did you hear about us?

If you selected other above, where or who did you hear about us from?