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Welcome
About
Services
Executive Virtual Assistance
Marriage & Family Therapy
Women Empowerment Speaking
Content
Blog
Podcast
Channel
Instagram
Newsletter
Shop
HLHW
Amazon
Contact
Living life by design!
Marriage & Family Therapy Consultation Intake Form
How did you hear about The Hardy Clinic?
*
Family Referral
Friend Refferal
Facebook
Google
Psychology Today
Instagram
School
Work
Insurance Provider
Therapy for Black Girls
Clayton County Public Schools
What type of appointment would you like to schedule?
*
Individual Sessions
Couple Sessions
Family Sessions
Are you aware that we are 100% virtual and currently ONLY offer online sessions?
*
Yes
No
Are you aware that we only serve clients who reside in the state of Georgia?
*
Yes
No
Client Information
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Preferred Method of Contact
*
Cell Phone
Email
Guardians full name(s) if client is under 18, list "n/a" if client is 18+. If for couples therapy provide partner's full name.
*
Please provide the guardian (if client is a minor) or additional partner's email address (if a couple).
*
Ethnicity
*
Client's Date of Birth
*
MM
DD
YYYY
Client's Marital Status
*
Single
Married
Divorced
Separated
Widowed
Client's Employment Status
*
Employed
Unemployed
Retired
Disabled
Student
Self Employment
Emergency Contact information
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Relationship
*
Insurance Information
Do you have insurance?
*
Yes
No
Type of Insurance
*
Cigna/Evernorth
Aetna
Tricare
United Healthcare/Optum/UMR
BCBS/Anthem
Self Pay/Pay Out-of-Pocket
Subscriber Name
*
First Name
Last Name
Subscriber Date of Birth
*
MM
DD
YYYY
Subscriber Relationship to Patient
*
Group Number
*
Policy Number
*
Medical History
Please check all that apply:
*
None
Allergies
Anemia
Angina
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Benign Prostatic
Blood Clots
Cancer
Cerebrovascular Accident
COPD (Emphysema)
Coronary Artery Disease
Crohn's Disease
Depression
Gallbladder Disease
GERD (Reflux)
Hepatitis C
Hyperlipidemia
Hypertension
Hypertrophy
Irritable Bowel Disease
Liver Disease
Migraine Headaches
Myocardial Infarction
Osteoarthritis
Osteoporosis
Peptic Ulcer Disease
Renal Disease
Seizure Disorder
Thyroid Disease
Other
Family History
Please check all that apply:
*
Adopted
Alcoholism
Allergies
Asthma
Arthritis
Blood Disease
CAD (Stroke)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
Mental History
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
*
Yes
No
Why are you seeking Therapy?
*
What do you expect from Therapy?
*
Thank you!