New Client Forms

Welcome!

If you are new to Haven Center and are scheduled for the initial intake appointment, we request that you print and fill out a Client Intake Questionnaire (either adult or child/adolescent) prior to your first visit. In addition, please fill out the Client Data Sheet and Client Charge Card Information Sheet.

Each member to be seen during family counseling needs to submit those three forms: the adult or child/adolescent questionnaire, as well as the other two forms.

Note: If the client is an adolescent (ages 12-18), please have the child fill out the adult intake questionnaire. That child’s guardian should fill out the child/adolescent intake questionnaire, as well as the client data sheet and client charge card sheet.

Select the appropriate questionnaires from the options below:

• Adult Intake Questionnaire
• Child/Adolescent Intake Questionnaire
• Client Data Sheet
• Client Charge Card Information Sheet

Please bring your insurance card with you on the first visit so that Haven Center may make a copy of it, as well as the credit or debit card information for Haven Center to keep on file. The charge card information may be used by Haven Center to cover late fees, if necessary. However, under special circumstances the client can use the charge card to cover cost of self-pay visits, or, in the case of clients using insurance, the cost of co-pays or coinsurance (see the charge card information sheet for details).

You may also fill out the questionnaires at Haven Center, but please come early in order to allow time to do so. The paperwork takes 20-30 minutes to fill out per individual, and will be reviewed with the client(s) during the intake session – so please complete the paperwork before the session.

Thank you! We look forward to working with you to accomplish your goals.