New Client Registration Form – Children & Adolescents

Individual Therapy (Children & Adolescents)

The first step to getting started as a new client at Wholehearted is to complete a New Client form. Once the form is completed, our admin team will review all of your information, including your reason for seeking services, your preferences around which therapist you’d be matched with, and your availability, and then we will be in touch about scheduling a first appointment. After the first appointment is scheduled, your account in the client portal will be set up and intake forms sent through the client portal (to your email). You will be expected to complete all of the forms by 3pm on the business day before your scheduled appointment. Meanwhile, our admin team will be verifying your insurance coverage and informing you of your financial responsibility before the appointment takes place. If you have any questions or want to follow up about the status of your new client form, you can contact us by email at admin@wholeheartedhc.org, or call/text us at 732-852-7373. In addition, if you’d like to follow along for practice updates and announcements, you can find us on Instagram at @wholeheartedhealingcollective

Youth's First Name:(Required)

Youth's Last Name:(Required)

Form completed by:(Required)

(first& last name)

Relationship to youth:(Required)

Self

Parent/Guardian

Other

Youth's Gender(Required)

Youth's Date of Birth:(Required)

Youth's Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(NOTE: your location at the time services are rendered is important due to licensing laws ; please specify if your home address is not in the same STATE as where you will be located during virtual appointments)

Parent/Guardian Contact Information

Parent's First Name:(Required)

Parent's Last Name:(Required)

Parent's Mobile Phone Number:(Required)

Parent's Email address:(Required)

Email address will be used for your access to the client portal & appointment reminders.

Youth (ages 16+) Contact Information

Youth's Mobile Phone Number (ages 16+):

Youth's Email address (ages 16+):

Email address will be used for your access to the client portal & appointment reminders.

Services

Type of counseling service(s) you'd like?(Required)

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Other

How did you hear about us?(Required)

If you were referred to us by a specific person, whether that is another provider or a loved one that is a client at WHC, please specify their name here.

Reason for seeking services?(Required)

Symptoms & concerns; please share as much as you feel comfortable sharing to help us match you with a therapist that can meet your needs.

What else would be important for us to know about your identity?

Race, culture, gender identity, sexual orientation, etc.

Therapist requested:(Required)

Please name any specific therapists on our team that you are most interested in seeing; or specify if you prefer a male or female, over 40 yrs old or under 40 yrs old; or any other preferences that you have. If you have no preferences, you can enter “n/a”

Child Custody Arrangement

Marital status of Child/Adolescents parents or guardians(Required)

Married/Together

Cohabitating

Separated

Divorced

Widowed

Never together/married

Parent/Guardian #2 Full Name:

If legal custody is shared between divorced/separated parents, please include email address for parent/guardian #2.

If legal custody is shared, please include phone number for parent/guardian #2.

Preferences

Are you comfortable with dogs?(Required)

No, I am not comfortable with dogs.

Yes, I am comfortable with dogs.

I am allergic to dogs.

Sometimes we have a pet dog in the office, but we have separate office spaces where no animals are allowed for those who aren’t comfortable or are allergic.

Would you be open to allowing a clinical intern to observe one of your sessions with your therapist?(Required)

Yes, I comfortable with a clinical intern observing one of my sessions.

No, I am not comfortable with a clinical intern observing one of my sessions.

WHC hosts graduate-level interns that are soon to be obtaining a clinical license of their. It aids significantly in their professional and clinical development to be able to observe our clinicians in session. If yes, we will send you an additional consent form, along with the rest of your intake paperwork.

Do you have any accessibility requirements you would like us to be aware of?

If you or a loved one are interested in one or more groups, please check all that apply:

Teen (13-17) DBT Skills Group

Child (6-12) DBT Skills Group

Adult (18+) DBT Skills Group

(If you are unsure about which group would be the best fit, or have questions about any of our groups, please email admin@wholeheartedhc.org)

If one of those groups checked off is for a loved one and not yourself, please specify here:

Insurance Information

Insurance Type(Required)

(i.e. Aetna, Cigna, Horizon; write n/a if you don’t have insurance – if you have insurance please complete all relevant fields below) NOTE: we are NOT in-network with medicaid/NJ Family Care or Medicare)

Insurance Member ID #(Required)

(write n/a if you don’t have insurance)

Insurance Group #

Policy Holder's First & Last Name:(Required)

Policy Holder's relationship to client:

Self

Partner/Spouse

Parent/Guardian

Policy Holder Date of Birth:

Policy holder address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Availability for Appointments

Which days and times are you available to schedule weekly appointments?(Required)

i.e. Mon or Thurs between 3pm-6pm Please offer at least a few times per week that could work for you.

Do you prefer telehealth or in-person?(Required)

In-person

Telehealth

A mix of both

Office is located in West Long Branch

Are you comfortable with communicating about scheduling by email and/or text?(Required)

Text is best

Email is best

Both are fine

I prefer that you do not text or email me. Please call.

Please upload the front and back of your insurance card.

Drop files here or

Max. file size: 256 MB, Max. files: 4.

Please upload the parent's photo ID & insurance policy holder's photo ID.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

New Client Registration Form – Children & Adolescents

Individual Therapy (Children & Adolescents)

Parent/Guardian Contact Information

Youth (ages 16+) Contact Information

Services

Child Custody Arrangement

Preferences

Insurance Information

Availability for Appointments

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