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Village Mindset, LLC

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

PRIMARY CLIENT INFORMATION

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PARTNER INFO

Second client Registration

PRIMARY INSURED

Insurance Self Pay EAP Third Party

May we call at work? YesNo

Primary Insurance Information

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SECONDARY INSURED ("If Applicable")

May we call at work? YesNo

Secondary Insurance Information

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Terms And Conditions

Hi and Welcome to Our Village!

Thank you for expressing interest in services here at Village Mindset, LLC, and becoming a part of our village. Please take a moment to read through our welcome letter and register today! A member of our team will reach out to you once we receive your completed online registration.


WHAT TO EXPECT?

We are confident that this is a question you may have been asking yourself as you contemplate scheduling your first appointment with us. We know that seeking services for things such as mental health concerns, business/career concerns, individual and/or family needs comes with a stigma today. We seek to create a warm and friendly environment where all our clients feel safe and secure no matter what is bring them in. With virtual services you can receive support from the comfort of your own home or wherever you feel most comfortable. We have taken the necessary steps to ensure that your privacy is maintained as our services are delivered via state-of-the-art HIPAA compliant platforms entitled Therasoft, RingRx, and Google Meets.


INTAKE PROCESS:

1) Online Intake Paperwork (policy documents, computer-based questionnaires). 

2) Free 15-Min Phone Call w/Intake Specialist or Client Coordinator

3) 30 Min- Consultation (Prepare/Enrich, Internship Placements, Board Supervision Services)

4) 60 Min-Intake Appointment (Coaching, Consulting, & Group Services)

5) 60 Min- Clinical Assessment. (Adult, Couple, Family, Group Therapy Services)


The purpose of Intake Appointment or the Clinical Assessment is to identify your current strengths, areas of need, determine program eligibility, discuss desired treatment outcomes, and/or make service recommendations. If it is determined that our firm or community center is not a good fit, we have client coordinators onsite to assist with locating up to three (3) community partners for alternative treatment options as well as case management services for on-going service coordination needs for an affordable fee. 



GETTING STARTED!

What's Next? Please take a moment to complete the online Intake Paperwork. Please do not hesitate to ask a question for clarity prior to signing any of our policy or consent documents.as well as the Payment, Authorization, and Attendance Policy. Please do not hesitate to ask a question for clarity prior to signing. The best way to reach us is via email at intake@villagemindset.org or give us a call at (757) 778-9800 to speak to a Intake Coordinator today. 


DISCLAIMER NOTICE: 

Please note that completion of the Intake Process does not guarantee that you will be enrolled in our services and accepted as a client. 

Please Note that all Intake Paperwork, Computer-based questionnaires, and payments are due within 48 hours of your scheduled appointment, or your Appointment Request will be declined. 



Respectfully,


Katesha S. Broadus, LCSW
CEO/Founder

Village Mindset, LLC
Mindset Adjusted Community Center

110 Coliseum Crossing #5050 
Hampton Virginia 23666
(757) 778-9800 (Tel)
(757) 778-9899 (Fax) 

General Inquiries:
Email: intake@villagemindset.org
Website: www.villagemindset.org


For technical support and inquiries please contact:
Therasoft Technical Support: 1 (888) 435-8203

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Village Mindset, LLC

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. What would your partner say?

5. Length of these relationship:

6. Can you tell me a little bit about yourself and your family/culture/upbringing?

7. Can you tell me a little bit about what intimate relationships look like for you?

8. Do you have any dependents?

9. Therapy before:

10. Psychiatry before:

11. Medications (type & dosage frequency):

12. Alcohol and Drug Use (type & dosage frequency):

Describe use:

13. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

14. Recreational drugs: Yes No

Describe use:

15. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

16. Self Harming Behaviours: Yes No

Describe, including most recent incident:

17. Violence Towards Others: Yes No

Describe, including most recent incident:

18. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

19. Experience of life being threatened by person, accident, or natural disaster: Yes No

20. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

21. Actions taken concerning above risks:

22. Religious Affiliation/Denomination:

23. Occupation:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. City Year Employee: (site name, site grade level, & program manager):

27. Availability:

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee: Insurance and/or Sliding scale amount:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

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Village Mindset, LLC

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

Intake

1. Occupation:

Youth worker:

No describe

Yes describe

2. If City Year Employee: (site name, site grade level, & program manager):

3. How did you hear about us?

4. What type of therapy are you seeking? Individual Couples Family Hybrid Group

5. What brings you in?

6. Client stated strengths

7. Can you tell me a little bit about yourself and your family/culture/upbringing?

8. Tell me a little bit about your community & social supports

9. Do you have any dependents?

10. Therapy before:

11. Psychiatry before:

12. Medications (type & dosage frequency):

13. Alcohol and Drug Use (type & dosage frequency):

Describe use:

14. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

15. Recreational drugs: Yes No

Describe use:

16. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

Access to any weapons, if so type:

17. Self Harming Behaviours: Yes No

Describe, including most recent incident:

18. Violence Towards Others: Yes No

Describe, including most recent incident:

19. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

20. Experience of life being threatened by: Person Accident Natural Disaster

21. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

22. Actions taken concerning above risks:

23. Religious Affiliation/Denomination:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. Availability:

27.Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

32. Youth worker: Yes No

33. Describe if not occupation (under occupation)

Secure Site

Village Mindset, LLC

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

5. Violence Towards Others: Yes No

Describe, including most recent incident:

6. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

7. Client Informed of Fee: Insurance and/or Sliding scale amount:

8.Client Notes

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Village Mindset, LLC

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

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Village Mindset, LLC

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

Intake

Intake Question

Referral Source

Are you currently on active duty? Yes No

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently using? Yes No

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral Yes No

If Children's Services referral, do you have an active Children's Services case? Yes No

# of children that you have

Crime Justus status

Probation Yes No

Parole Yes No

PROB 45 Yes No

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed Yes No

Sober Housing Provided Yes No

Medical Intake Questions

If female, are you pregnant? Yes No

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip code

County

Is there a history of drug use? Yes No

In the past 30 days, where have you been living most of the time?

Are you currently employed?

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Expiration Date:

Address:

Zip:

A valid debit or credit card number is required to complete registration. All federally required safety measures are in place to protect your financial and private health information.

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Electronic Signature

Village Mindset, LLC

110 Coliseum Xing #5050Hampton VA 23666 757-778-9800

PRIMARY CLIENT INFORMATION

PARTNER INFO

PRIMARY INSURED

Primary Insurance Information

SECONDARY INSURED ("If Applicable")

Village Mindset, LLC

110 Coliseum Xing #5050Hampton VA 23666 757-778-9800

Village Mindset, LLC

110 Coliseum Xing #5050Hampton VA 23666 757-778-9800

Village Mindset, LLC

110 Coliseum Xing #5050Hampton VA 23666 757-778-9800

Village Mindset, LLC

110 Coliseum Xing #5050Hampton VA 23666 757-778-9800

Village Mindset, LLC

110 Coliseum Xing #5050Hampton VA 23666 757-778-9800

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800

110 Coliseum Xing #5050
Hampton VA 23666
757-778-9800