Mental Health Therapy Participant Intake Form

Date of Intake*

Referral Source*

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PARTICIPANT INFORMATION

First & Last Name*

Preferred Pronouns

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Phone Number*

E-mail*

May we leave a voicemail?

Yes

No

DEMOGRAPHICS

Age*

Zipcode of Residence*

Gender*

Male

Female

Gender X (I do not identify as either exclusively male or female)

Prefer not to say

Race Specific for AANHPI (Select all the apply)

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Ethnicity*

Hispanic or Latino

Non Hispanic or Latino

Not Applicable

Housing Status*

Institutional Situations (live-in rehab facilities providing therapy for substance abuse, mental illness, or other behavioral problems)

Homeless situations (being at risk of losing housing; without a permanent house, housing, or place to live)

Stably Housed (having a stable and permanent place to live)

Unknown (You are not sure, which is okay.)

Veteran Status*

Veteran

Non-Veteran

Not Applicable

PARTICIPANT CERTIFICATION

To qualify for up to 5 cost-sponsored mental health therapy sessions, individuals must certify that they have a financial barrier, do not have insurance, or have used up all of their insurance benefits.

Please share what barrier you are experiencing that prevents you from accessing mental health therapy?*

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Indicate your barrier to accessing therapy/counseling.

What days and times are you most available for mental health therapy sessions?*

Please indicate which of our partnered therapist/organization you most prefer to be reffered to*

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Is this your first time seeking mental health counseling?*

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Participation Understanding*

I understand that I am seeking this free mental health therapy services from Asia Pacific Cultural Center and that I should attend all of my scheduled counseling appointments to the best of my ability. If I am unable to attend, I will notify my therapist and the APCC staff contact at least 24 hours in advance and reschedule. Call APCC at 253- 414-7208.

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Participation Understanding*

I understand that if I miss at one of my scheduled counseling sessions and did not notify my therapist or APCC staff, I will no longer be able to access this free service.

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Send me a copy of my responses