Abide.Network Intake Form-ABIDE Network

Abide.Network Intake Form

Fill out this form to be paired with one of our coaches. Average time is 15–30 mins. Response time is 2-5 days.

Terms of Service

LIABILITY

Abide Network is a referral service. As such it does not establish a counselor/client relationship with persons seeking referrals. Neither is Abide responsible for, nor have oversight of, the relationship between the coach and the client.

INSURANCE

Sessions through Abide Network are not generally covered by insurance. If your provider is licensed in your state, you are free to ask them for a superbill, which your insurance may reimburse. But it is best to assume you will pay fee-for-service.

Are you over 18 years of age?

Yes

Are you filling out this form for yourself or someone else?

Myself

Someone else

If someone else, is the person a minor? *

Yes

N/A

If you are filling the form out for a minor, what is your name and how are you related to the person?

Personal Information

About the individual receiving services

First name

Last name

Date of Birth

Phone Number

Address

Occupation

List children and their ages, if any

Financial Information

Our certified coaches have been trained by Dr. Jennifer Schwirzer in empathic listening, emotional support, and basic principles and techniques of mental and relational health. Their sessions range in price from $25-$60. Our professional counselors, whom Dr. Schwirzer has also trained, have earned graduate degrees, national certifications, and/or state licenses. They range in price from $60-$150. Our intake supervisor, Jeanine Goodwin, RMFT, can help place you with the person best suited to your needs.

How would you like to begin your journey towards improving your mental health?

Choose what you think will work best

Masters Level Coach: $65-$125 per session

Certified Coach: $30-$60 per session

I am unable to pay, and willing to wait until a certified coach is available in the future

Pick which option best describes your situation:

Student

Senior citizen on a fixed income

Financial Hardship (explain below)

None of the above

Explain your financial situation

Religious Background

Denominational Preference

Is faith an important part of your life? Is faith an important part of your life? Explain:

Health History

List all important past injuries or handicaps:

Do you have any current medical conditions? If so, please explain:

Mental Health History

List all important past mental health problems you’ve experienced:

Do you have a history of suicide attempts? If so, please explain:

Do you currently suffer with any psychotic episodes? If so, please explain:

Do you have any current mental health diagnoses? If so, please explain:

Mental Health Providers:

List any current providers you have, including address and phone

Please list any medication, dosage, frequency and for which conditions.

Is the medication effective?

Yes

N/A

Are you adhering to the suggested medication use?

Yes

N/A

Have you ever used drugs for purposes other than medical? If yes, explain:

Yes

N/A

Are you dependent on any drugs or alcohol?

Yes

Do you smoke?

Yes

Use this space to give more details about your history.

Prior Treatment

Previous mental health (MH) and substance abuse (SA) treatment: Please list most recent first.

Date, provider, level of care, duration, condition (MH/SA), outcome.

Family/Environmental

List any history of mental health or substance abuse diagnoses in your family that you are aware of, using specific labels such as “alcoholism” or “depression.”

Mother/Father/Spouse or SO / Child / Other

Did you ever experience any emotional/physical or sexual abuse as a child?

Yes

Is there anything else significant about your childhood that you feel would be helpful to mention at this time?

Provider Preferences

Please note that, at any point, you may make a request to the Intake Supervisor if you'd like to try coaching with a different coach. Leave blank if you have no preference. Our coordinator will make sure to match you with the most optimal one.

Browse available coaches by clicking here.

Which Abide counselor or coach do you prefer, if any?

Are you flexible if that person isn’t available?

Yes

Do you prefer male, female, or either?

Female

Male

Either

Please write a paragraph or so about what leads you to seek help. What symptoms are you experiencing? What kind of interpersonal problems would you like to solve? Please give all relevant information.

Sign & Submit

Terms and Conditions

Abide Network coaches and counselors reserve the right to refer clients elsewhere should they display acute mental health problems, suicidality, current substance abuse, and complex legal issues. The coach or counselor may continue or discontinue coaching the client. This is subject to circumstances pertaining to each situation.

Everything discussed in the coaching sessions will be between only the coach and the client, unless the client gives permission to share information to specific individuals, or the client reveals information that indicates a threat of harm to self or others, as required by professional ethical standards.

I agree to the terms & conditions

Today's Date

By typing your full legal name you agree to allow Abide Network to receive this form.