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Welcome to Think Happy Live Healthy

Ready to book an appointment?

Once you complete this form you will receive an automated email letting you know that we received the form. You will hear from us within 24-48 hours to schedule your appointment. Please check your SPAM folder as our emails sometimes go to spam. If you do not receive an automated response please reach out to

Client First Name

Name of person completing this form

Client Last Name

Client Date of Birth

Phone

Email Address

Address (please include city/state)

Client's sex

What insurance do you have?

What is your insurance subscriber (member) ID number? (If you have BCBS, we need the 3 letter alpha prefix along with the ID#)

What is your insurance group number? (For FEP Blue Cross Blue Shield plans: it's the 3 digit enrollment code)

Insurance subscriber name, DOB, and sex?

Referred by:

Reason Seeking Treatment

Anger/Aggression

Anxiety

Attention Deficit Hyperactivity Disorder

Autism

Bipolar Disorder

Depression

Disruptive Behavior Disorder

Eating Disorder

Educational Exploration

Family Conflict

Life Transitions

Obsessive Compulsive Disorder

Oppositional Defiance

Parenting Support

Personality Disorder

Post Traumatic Stress Disorder

Psychosis

Relationship Issues

Schizophrenia or Schizoaffective Disorder

Stress Management

Shyness

School Refusal

Vocational Exploration

Postpartum depression/anxiety

Other

Describe in detail why you are seeking therapy at this time.

When are you available to come in for ongoing appointments?

Weekday mornings

Weekday afternoons

Weekday evenings

Weekends

Please email a CLEAR, CLOSE UP picture of the front and back of your insurance card to info@thinkhappylivehealthy.com and put the client's name and DOB in the subject line and state you have completed this intake form. Mark "Yes" that you understand and will submit a picture of your insurance card.

Would your child be interested in attending a boys or girls support group?

Yes

No

Maybe

Are you interested in a psychological evaluation/testing?

Yes

No

Maybe

Please state what therapist you'd like to work with.

I declare that the info I have provided is accurate and complete

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256 N. Washington St., Suite 2

Falls Church, VA 22046

703-942-9745