VILLAGE COUNSELING SERVICES
Welcome
Services
Lawrenceville Clinicians
Cape May Clinicians
Appointments
Intake Form
Group Schedule
Resources
Contact Us
Confidential Intake Form
Please fill out the Intake form, and someone will contact you to set up your first appointment. Please be sure to leave at least one contact phone number where you may be reached between 9 am and 1 pm, Monday through Friday.
If you are not the client, but referring a client to us, please leave your name, address, phone and email address.
Please fill out the rest of this form as if you were the client.
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Indicates required field
Name
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First
Last
If you are not the client, but referring a client to us, please leave your name, address, phone and email address.
Please fill out the rest of this form as if you were the client.
Referred by:
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Date of Birth:
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Social Security Number:
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Phone number where you can be reached 9am-pm M-F:
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Additional Phone Number:
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Email Address:
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Home Address:
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Who referred you, or where did you find out about VCS?
(If referred, please include name, address, email and phone number of referrer)
Name/address/number of referrer:
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If known, please indicate the type of treatment you are seeking:
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Individual Psychotherapy
Family Psychotherapy
Psychiatric Evaluation/Medication Management
Psychological Testing & Diagnostic Evaluation
Dialectical Behavior Therapy Program (DBT)
Mindfulness-Based Cognitive Therapy (MBCT)
Eye Movement Desensitization Reprocessing (EMDR)
Emotionally Focused Couples Therapy (EFT)
Cognitive-Behavioral Hypnotherapy (CBH)
Have you been a client of VCS in the past?
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Yes
No
Are you currently on any medications for your mental health?
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Yes
No
Who prescribes your current mental health medication? Please provide the name telephone number of the doctor:
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If you are seeking medication management, please give us the name, address and telephone number of your pharmacy:
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Do you prefer a female or male therapist?
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Female
Male
Any available
Please list your availability (for instance, "during the day," or "evening only, " or "any day but Wednesday":
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Will you be using an Employee Assistance Program (EAP) Benefit from your Employer? If so, please provide the EAP Name, Contact person and contact phone number:
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What is the name of your primary insurance company? (For example, Blue Cross, or Medicare):
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What is the insurance type? (For example, POS, PPO, HMO, etc.):
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Name of the subscriber (if not yourself):
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Social security number of subscriber (if not yourself):
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Subscriber's date of birth (if not yourself):
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Relationship of subscriber to the client:
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Insurance ID number:
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Insurance group number (If your insurance card does not have a group number, please enter N/A):
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Do you have a secondary insurance? If you do, please fill out the Secondary Health Insurance questions that follow. If not, please click "Submit" and we will contact you with appointment times. Thank you!
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Yes
No
Secondary health insurance company name:
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What is the secondary insurance type? (For instance, POS, PPO, HMO, etc.)
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Name of the secondary insurance subscriber (if not yourself):
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Subscriber relationship (secondary insurance):
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Self
Partner/Spouse
Mother
Father
Subscriber's date of birth for secondary (if not yourself):
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Secondary insurance ID number:
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Secondary insurance group number:
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Secondary insurance subscriber is employed by:
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Subscriber address, if different from above (secondary insurance):
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Secondary provider phone number, or phone for mental health or behavioral health benefits:
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Comments:
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Submit
Welcome
Services
Lawrenceville Clinicians
Cape May Clinicians
Appointments
Intake Form
Group Schedule
Resources
Contact Us