Forms

Counseling intake forms
To speed services on the day of the intake appointment, the following forms may be printed, completed by the client or client’s parent/guardian, and given to the AGAPE receptionist upon arrival at the AGAPE office:

• Client Information Form (2 pages)
• AGAPE Symptom Checklist (1 page)
• AGAPE Client History (1 page)

Note: The agreement below is specific to the Nashville ( Trousdale Drive ) office only. For affiliate offices, you will need to pick up a hard copy of the agreement that this specific to that location. It is effective July 1, 2008.

• Nashville Office Therapist –Client Services Agreement (6 pages)

VERY IMPORTANT

Please check your insurance benefits

Prior to calling AGAPE to arrange counseling or psychological services we ask that you obtain certain important information regarding your insurance. This will greatly speed the process of matching you with the most appropriate mental health professional from our staff. Refer to the back of your insurance card and call the number listed for “mental health” or “behavioral health” benefits. Ask the representative at that number for the following information pertaining to your out-patient mental health benefits:

1. The name of your “behavioral health organization” (e.g., Magellan, UBH, Value Options, etc.)
2. Your deductible amount and date new year begins
3. Your co-pay amount