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Front Office Intake Forms

Assessment Forms

LIFE-STYLE ASSESSMENT

A great way to save you some time and money is to complete the Life-Style Assessment form. This gives your WPS Counselor a great foundation of information so you can hit the ground running from the very first session. It may look similar to the Personal History Questionnaire to you - but the questions reveal other information to help your treatment. Your WPS Counselor may ask you to complete both this assessment and the Personal History Questionnaire.

PERSONAL HISTORY QUESTIONNAIRE

Help yourself and your WPS Counselor save you some time and money by immediately identifying some of the problems with which you are seeking assistance. Similar at first glance to the Life-Style Assessment, this form asks questions of a different nature. Your WPS Counselor may ask you to complete both this form and the
Life-Style Assessment.

DEPRESSION SCREENING ASSESSMENT

The results from this questionnaire will help your WPS Counselor to review if you have been bothered by symptoms of depression.

SOCIAL ANXIETY DISORDER ASSESSMENT

Your WPS Counselor can help you with evaluating factors that might cause you anxiety in social situations.

INFORMATION RELEASE FORM

This form is used to identify another organization and/or person(s) for information and to give them permission to release it to Wicks Psychological Services for the treatment of the client.

INSURANCE AUTHORIZATION FORM

Use this form to identify insurance carrier information and to grant authorization for insurance to be applied.

CLIENT INFORMATION FORM

-CHILDREN & ADOLESCENTS-

This is for new clients to be filled out by a parent or guardian for a child or adolescent under 19 years old.

Complete these forms only as instructed by the Front Office or your Counselor

CLIENT INFORMATION FORM

-ADULTS-

This is for new adult clients to be filled out by the client or the client's spouse / sponsor. This also includes information release, insurance authorization and office policy acknowledgement.

YALE-BROWN OBSESSIVE COMPULSIVE SCALE

Also known as the Y-BOCS for short, this assessment helps you and your WPS Counselor reveal if you may or may not have OCD issues.

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