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Welcome to Think Happy Live Healthy

You must be a Virginia resident to receive Telehealth services.

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. Please check your SPAM folder as our emails sometimes go to spam. If you do not receive an automated response please reach out to info@thinkhappylivehealthy.com

ONLY ONE FORM PER CLIENT!

CLIENT FULL NAME

Name of person completing this form

Client Date of Birth

Client's sex/gender identity

Phone

Street Address

City, State, Zip

Email Address

What insurance do you have?

What is your insurance subscriber (member) ID number?

What is your insurance group number?

Insurance subscriber name, DOB, and sex?

Referred by:

Are you a former client, wanting to return to therapy?

Do you have a family member receiving services from us currently?

Reason Seeking Treatment:

Anger/Aggression

Anxiety

Attention Deficit Hyperactivity Disorder

Autism

Bipolar Disorder

Depression

Disruptive Behavior Disorder

Anorexia

Binge Eating Disorder

Bulimia

Disordered Eating Patterns

Compulsive Overeating

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

Grief/Loss

Suicidal Ideation

Self Harm Behavior

Issues with Sexual Orientation

Issues with Gender Identity

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

Do you understand that we only provide teletherapy at this time and that you must physically be located in the state of VA for telehealth visits? You must be a VA resident. Psychological Testing is held on-site at our Falls Church location.

When are you available for ongoing appointments? NOTE: Daytime appointments are more readily available.

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

Yes

No

Maybe

Please state what service you are interested in.

Individual Therapy

Couples Therapy

Individual Counseling & Psychological Testing

Psychological Testing

Parent Consultation

What therapist would you like to work with?

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256 N. Washington St., Suite 2

Falls Church, VA 22046

703-942-9745

info@thinkhappylivehealthy.com