Thank you for your interest in Intuition Wellness Center. Here is some information that may be helpful:

• Intuition Wellness Center serves individuals ages birth to 30 and caregivers.
• Some services are billable to Blue Cross Blue Shield and Aetna insurances.
• Self pay fees for services are available to view on our Fee Schedule.
• Intuition Wellness Center’s training department, which consists of graduate-level doctoral students, provides some services at a reduced fee. Typically, these services are not billable to insurance.
• Team members at Intuition Wellness Center have limited availability. Prospective clients with flexibility of scheduling and team member preference are the most successful in matching to services.
• The Intuition Wellness Team values a thoughtful process when it comes to matching potential clients with a provider. It typically takes 3-7 days for the team to formulate a response to requests for an appointment. Occasionally the wait may be a bit longer, such as during holidays or times when the volume of requests is particularly high. Thank you for your patience.
• If you are seeking information on our Wellness Programs, you are not required to complete the following questionnaire.

The questionnaire below is required in order to determine Intuition Wellness Center’s ability to meet your needs for clinical services. To request services, please call 520-333-3320 or complete the following prospective client questionnaire:


Your Name (required)


Your Email (required)



Would You Like to Sign Up for Our Newsletter?
YesNo


Your Phone (required)



Who Are You Seeking Services For? (required)

Self (adult)ChildFamily


If seeking services for someone other than yourself, what is their name: (required)



Sex Assigned at Birth of Prospective Client?
MaleFemaleOther


Date of Birth of Prospective Client (required)



If client is a child, what school do they attend?


School Grade



How did you hear about Intuition Wellness Center? (required)
BCBSAetnaPsychology TodayInternet (eg., Google)PCPOther ProfessionalOther


Do you have a preference of clinical team member: (Select all that apply; required) Team members have limited availability. Flexibility increases the chance of a successful match.
Any Licensed ClinicianDoctoral StudentBrandy Baker, Psy.D.Emily Fenton, LCSWKacey Greening, Psy.D.Sherrill Koogler, LCSW, RPTNavneet Lahti, LCSWLindsay Lennertz, Psy.D.Gabe Rischall, LCSWAnne Swiderek, OTR/LYoendry Torres, Psy.D.


What service(s) are you requesting? (Select all that apply; required)
CounselingPlay TherapyParent GuidanceTestingPediatric Occupational TherapyParent-Child Relationship AssessmentSchool Success ConsultationYogaParent Education


If you are interested in enrolling in Taekwondo classes, please visit the TKD Wellness website.


Symptoms (Select all that apply; required):
AnxietyDepressionAngerADHDSelf-HarmDivorce/FamilyFine MotorHandwritingGross MotorFeedingSensoryOther


Please describe your concerns in just a few sentences:



Is the prospective client seeking treatment for the following (required):
Eating DisorderAddictionNone of These
If so, please provide just a little more detail:



Does prospective client have a history of chronic substance abuse? (required)
YesNo
If so, please provide just a little more detail:



Does prospective client have a significant medical complication? (required)
YesNo
If so, please provide just a little more detail:



Did prospective client recently attempt suicide? (required)
YesNo
If so, how recently?:



Is prospective client currently suicidal? (required)
YesNo
(If so, please call 911 or the crisis line at 1-866-495-6735 to speak to a crisis counselor.)


Does the prospective client have a history of aggression or violence or are they currently aggressive or violent? (required)
YesNo


Did prospective client recently attempt homicide? (required)
YesNo
If so, how recently?:



Is prospective client currently homicidal? (required)
YesNo
(If so, please call the crisis line at 1-866-495-6735 to speak to a crisis counselor or call 911.)


Has prospective client had any past or current legal involvement, including parental divorce proceedings or Department of Child Services (DCS/CPS)? (required)
YesNo
If so, please specify:



If requesting services for a child, are both parents available to consent to treatment?
YesNoNA, prospective client is an adult
If not, please give a little more detail:


If requesting services for a child, has either parent’s rights been legally terminated?
YesNoNA, prospective client is an adult
If so, please give a little more detail:


Who has power to make medical decisions for the prospective client according to the law?


Please supply supporting court documents at intake or scan and email them to contact@intuitionwellness.com prior to your intake appointment.





Prospective testing clients only:

Are you requesting an evaluation for a brain injury?
YesNo


Are you requesting a full Autism Spectrum Disorder evaluation?
YesNo


Does prospective client have a previous treatment history? (required)
MedicalBehavioral HealthOtherNone
If so, please give a little more detail:


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. You can also email PDF documents to contact@intuitionwellness.com.


How would you like to pay for services: (required - See Fee Schedule)
Licensed Team Member - See Fee ScheduleDoctoral Student - See Fee ScheduleBCBSAetna


If you choose Insurance payment, please provide the following information for insurance verification (Please note that doctoral students counseling services are not billable to insurance):
Insurance ID:
Group #:
Subscriber Name:
Subscriber Date of Birth:


Thank you for taking the time to complete the questionnaire. Please click “Request an Appointment” to submit to the Intuition Wellness Center team for review and processing.