Pre Appointment Questionnaire

Elaine Kates PsyD, LCSW

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Pre Appointment Questionnaire

Contact and Initial Information Form
*Only questionnaires received within the last 90 days will be contacted for waiting list
831-464-7400

* Indicates required field

Name *

First

Last

Home phone *

Is it alright to leave a message on your home phone? *

yes no

Cell phone *

Is it alright to leave a message on your cell phone? *

yes no

Is it alright to text you? *

yes no

Email *

Is it alright to email you? *

yes no

Please list your Primary Insurance Carrier *

Please list: Name and type of plan (HMO,PPO,POS) Member #, Date of Birth, and 800# for Mental Health Providers. So I can check your coverage and advise you accordingly

Do you have any other Insurance Carriers? Perhaps under a parent's/spouse's plan?) *

Please list: Name and type of plan (HMO,PPO,POS) member # birthdate and 800 number for mental health providers, so I can check your coverage and advise you accordingly

Please provide a brief description of why you might be coming into therapy. *

How long have been experiencing these symptoms or issues? *

Less than 1 month 1-6 months 1-3 years Over 3 years

Which of the following might apply to you that you would like to address? *

Depression Anxiety/ Social Anxiety/ Panic Chemical Dependency Problems STDs/ HIV/ HPV etc Low Self-Esteem Grief and Loss Trauma Domestic Violence GBLT Relationship Issues ADHD & Learning Disabilities Eating Disorders Life Transition Behavioral Difficulties (Drugs/Alcohol, Sex, Gambling, Overeating, Shopping or Overspending, etc) Practical Life Skills & Organization Nutritional Guidance and General Self-care Potential Medication Referral Solutions to finding out who you truly are and becoming the person you want to be Educational/ Career Issues Occupational Issues Sleep problems Other

Any additional information I should know? *

How did you find me? *

Internet Search Professional Referral Friend UCSC CAPS Other

These questions are to help me serve you better and improve my overall services
Optional but appreciated.

Choose One *

Male Female

Your Age Group *

Less than 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

Income (yours or if student, family) *

Less than $10,000 $10,001-$25,000 $25,001-$40,000 $70,001-$100,000 > $100,000 Prefer not to say

Call 831.464.7400

Submit

Contact and Initial Information Form*Only questionnaires received within the last 90 days will be contacted for waiting list831-464-7400

These questions are to help me serve you better and improve my overall servicesOptional but appreciated.

Call 831.464.7400

Contact and Initial Information Form
*Only questionnaires received within the last 90 days will be contacted for waiting list
831-464-7400

These questions are to help me serve you better and improve my overall services
Optional but appreciated.