Consent Forms

Mental Health Therapy Polices

Click here to read and fill out the Policies.

Informed Consent

Click here to read and fill out the Informed Consent Form.

Release of Client Information Form

Click here to read and fill out the Form.

Statement of Understanding

Click here to read and fill out the Statement of Understanding.

By checking this box, I indicate that I have read, understand and agree to the above Statements and Consent Forms provided by the staff of the Work+Life Connections Program.

YesNo

Suggested Resources

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Has it been longer than one year since you have seen a Work+Life Therapist?

YesNo

Fill out the following below.

Client Legal First Name

Client Legal Last Name

Preferred Name

How do you identify?

Gender Identity

Client Preferred Pronouns

Client Other Preferred Pronoun

Client Last 4 of Social Security Number

Client Mobile Phone

Client UK Affiliation

Link Blue of UK Employee

Page 1

Client Intake Form

Client Contact Information

Client Legal First Name

Client Legal Middle Name

Client Legal Last Name

Client Preferred Name

Client Preferred Pronouns

Client Other Preferred Pronouns

Please include client's preferred pronoun(s) not listed in the dropdown options.

How do you identify?

Gender Identity

Client Last 4 of Social Security Number

Client Date of Birth MM/DD/YYYY

MM/DD/YYYY

Client Mobile Phone

OK to send booking notifications via text message to mobile phone number?

Yes

No

If yes is selected you are giving permisson for booking notifications to be sent to your mobile phone via text message.

Can a detailed message be left on your mobile number?

Yes

No

If yes is selected you are giving permission for detailed voice messages to be left on your mobile phone.

Client Alternate Phone Number (optional)

Can a detailed message be left on your alternate number?

Yes

No

If yes is selected you are giving permission for detailed voice messages to be left on your alternate phone number.

Client Preferred Email

Booking notifications will be sent to this email.

Client Preferred Method of Contact

Client Physical Address

City

State

Zip Code

Client UK Affiliation

Role of UK Benefits Holder

Click here to see if you qualify as a sponsored dependent.

What is your Relationship to the UK Affiliate?

First Name of UK Employee

Last Name of UK Employee

Link Blue Id

Link Blue Id of UK Affiliate

UK Employee ID

Also referred to as a UK ID number.

Work Department of UK Employee

Has any family member(s) or relationship partner been seen by a Work+Life Therapist?

YesNo

Name of family member(s) or relationship partner being seen at this office.

Do you need to update your Emergency Contact?

YesNo

Client Emergency Contact

First Name of Emergency Contact

Last Name of Emergency Contact

Phone Number of Emergency Contact

Relationship of Emergency Contact

Do you need to update your Insurance Information?

YesNo

Client Insurance Information

Client Insurance Provider

Only select "Other" if your insurance is not through the University of Kentucky. If insured through the University of Kentucky plese select EPO, HMO, Indemnity, PPO, or RHP.

Client Other Insurance Provider

Client Medical Information

Do you currently take any medications?

YesNo

Please list medication, dosage, purpose and prescribing doctor.

Have you been to counseling before?

YesNo

Have you been to counseling since your last Work+Life session?

YesNo

Please list service provider(s), approximate dates of service, primary issue(s).

Please provide a brief description of why you would like a counseling session.

General

May we email you a brief survey at the end of your visits?

YesNo

How did you hear about us?