Perspective Client Screening Thank you for your interest in Intuition Wellness Center. Here is some information that may be helpful. We treat ages birth to 30. We accept Blue Cross Blue Shield and Aetna insurances. Our self pay rates for counseling are $200 for the intake appointment and $165 each additional visit. These rates are based on a 1 hour session. Another alternative that we provide is the use of University of Arizona psychology externs. Our current psychology externs are each working toward a doctoral degree in psychology at the University of Arizona and are supervised by a licensed clinical psychologist. Intuition Wellness’ extern program provides a structured practicum focused on providing students with high quality supervision and training. Since they cannot bill insurance, their rates are discounted. The intake rate is $100 and $75 for each additional visit. These rates are based on a 1 hour session. If you are interested in any of the options above, please give me a call at 520-333-3320 or to see the rates for other services please see our fee schedule Please note that our caseloads are almost full, and the screening below is required in order to determine availability. Your Name (required) Your Email (required) Would You Like to Sign Up for Our Newsletter? YesNo Your Phone (required) Subject Who Are You Seeking Services For? (required) Self (adult)ChildFamily Gender? MaleFemaleOther Date of Birth If client is a child, what school do they attend? School Grade How did you hear about Intuition Wellness Center? BCBSAetnaPsychology TodayInternet (eg., Google)PCPOther What is Your Clinician Preference: (required) Brandy Baker, Psy.D.Emily Fenton, LCSWKacey Greening, Psy.D.Sherrill Koogler, LCSWNavneet Lahti, LCSWLindsay Lennertz, Psy.D.Anne Swiderek, OTR/LYoendry Torres, Psy.D.Open to Any Licensed ClinicianOpen to Psychology Extern What service are you wanting? (required) CounselingPlay TherapyParent GuidanceTestingOccupational TherapyTaekwondoYogaParent Education Does client had previous treatment history? (required) MedicalBehavioral HealthOtherNone If you have previous behavioral health or medical treatment history, please bring a copy of records (e.g., treatment summary, treatment plan, testing reports, etc) at the initial intake appointment or you can scan and email PDF documents to firstname.lastname@example.org. How Will You be Paying for Services: (required) Licensed Clinician ($200/$165)Psychology Extern ($100/$75)BCBSAetna If you choose Insurance payment, please provide the following information for insurance verification: Insurance ID: Group #: Subscriber Name: Subscriber Date of Birth: Presenting Symptoms: AnxietyDepressionAngerADHDSelf-HarmDivorce/FamilyFine MotorHandwritingGross MotorFeedingSensoryOther Please describe concerns briefly: Is client seeking treatment for any of the following: Eating DisorderAddictionNone of These If so, please specify: Does client have a history of chronic substance abuse? YesNo Does client have a significant medical complication? YesNo If so, please specify: Did client recently attempt suicide (not suicidal ideations/thinking) or are they currently suicidal? YesNo (If so, please call the crisis line at (520) 622-6000 to speak to a crisis counselor. Does the client have a history of aggression or violence or are they currently aggressive or violent? YesNo Did client recently attempt homicide (not homicidal ideations/thinking) or are they currently homicidal? YesNo (If so, please call the crisis line at (520) 622-6000 to speak to a crisis counselor or call 911. Has client had any past or current legal involvement, including parental divorce proceedings or Department of Child Services (DCS/CPS)? YesNo If so, please specify: Has either parent’s rights been terminate? YesNo If so, who? Who has power to make medical decisions? ? Please supply court documents at intake or scan and email them to email@example.com prior to your intake appointment. Testing clients only: Are you requesting an evaluation for a brain injury? YesNo (If so, please know that we do not specialize in this type of assessment) Are you requesting a full Autism Spectrum Disorder evaluation? YesNo Thank you for taking the time to complete our screening form. Please click submit to send the form to our front desk for review and processing.