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
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Name
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First
Last
Home phone
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Is it alright to leave a message on your home phone?
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yes
no
Cell phone
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Is it alright to leave a message on your cell phone?
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yes
no
Is it alright to text you?
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yes
no
Email
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Is it alright to email you?
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yes
no
Please list your Primary Insurance Carrier
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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?)
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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.
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How long have been experiencing these symptoms or issues?
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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?
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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?
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How did you find me?
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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
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Male
Female
Your Age Group
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Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
Income (yours or if student, family)
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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