Korey Eckley, LCSW, LLC | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Gender (optional)

Please indicate how I may contact you (check all that apply)

Phone Call Text E-mail

Reason for care

What is the reason for seeking care?

*if you are under the age of 18, please ask your guardian to submit paperwork.

Anxiety: ie.feeling nervous, on edge, not able to control worry or trouble relaxing Attention difficulties: ie ADHD symptoms such as focus, time management, emotional regulation, impulsivity. Behavioral issues: ie. frequent conflict with others, irritability or anger outbursts, defiance, rule-breaking, impulsive or risky behavior, aggression (verbal or physical). Depression: ie.persistent sadness, loss of interest or pleasure, low motivation, fatigue, feelings of hopelessness or worthlessness, changes in sleep or appetite,, low self-esteem, isolation Grief or major life changes: ie, coping with the death of a loved one or meaningful losses such as divorce, estrangement, miscarriage, health, career transitions, relocation, or identity shifts. Relationship issue: ie conflict, communication problems, difficulty with trust or boundaries, recurring relationship patterns, or distress in romantic, family, or social relationships. Substance use: ie hard to control use of alcohol or drugs , ↑ tolerance, using substances to cope with stress or emotions, cravings, withdrawal symptoms, negative impact work/social Trauma: Past or ongoing experiences that feel unsafe(including abuse, neglect, bullying, loss, medical events) that impact e to affect mood, relationships, or daily functioning Other

Age Requirement

In Indiana, therapy for minors requires the consent of a parent or legal guardian. If you are inquiring about services for someone under 18, a parent or legal guardian must be involved in the intake and consent process before services can begin.

I am 18 or older I am under 18.

If you are under 18, please provide parent/legal guardian contact information. This gives me permission to reach out to your guardian. If you are 18 or older, please type in NA.

Are you currently involved in any legal or court-related matters? If yes, please briefly describe (e.g., custody case, criminal charges, probation requirements, court-ordered treatment, etc.):

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

If you have a specific question, please list it below. (ie. insurance, rates, sliding scale etc).

If there are no current available times within your requested appointment times, would you like to be added to the waitlist.

If there are no current available appointment times, add me to the waitlist? Please, do not add me to the waitlist.

Billing & Payment

Payment and Insurance method

Coverage & Benefits:

Insurance Providers

I plan to use my insurance, which is UMR or United Behavioral Health.

Client Preferences

Preferred appointment times

*Please note that evening and weekend have limited availability .

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know about you?

For example: What brings you to therapy? What do you want to focus on in therapy? Is there something helpful for me to know about you?

What is your preference of location for therapy?

I prefer in person therapy.

I prefer virtual therapy (phone or video). I don't have a preference. Other

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.