Elaine Kates PsyD, LCSW
Pre Appointment Questionnaire
Contact and Initial Information Form
*Only questionnaires received within the last 90 days will be contacted for waiting list
Is it alright to leave a message on your home phone?
Is it alright to leave a message on your cell phone?
Is it alright to text you?
Is it alright to email you?
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 parents/spouses 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
Over 3 years
Which of the following might apply to you that you would like to address?
Anxiety/ Social Anxiety/ Panic
Chemical Dependency Problems
STDs/ HIV/ HPV etc
Grief and Loss
ADHD & Learning Disabilities
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
Any additional information I should know?
How did you find me?
These questions are to help me serve you better and improve my overall services
Optional but appreciated.
Your Age Group
Less than 13
Prefer not to say
Income (yours or if student, family)
Less than $10,000
Prefer not to say