Pre Registration

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JCCTA

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

PRIMARY CLIENT INFORMATION

Click here to enter Additional Client Info

Click here to enter Partner Information

PARTNER INFO

Second client Registration

PRIMARY INSURED

Insurance Self Pay EAP Third Party

May we call at work? YesNo

Primary Insurance Information

Click here if you have Secondary Information

SECONDARY INSURED ("If Applicable")

May we call at work? YesNo

Secondary Insurance Information

Click here to enter Terms Information

Terms And Conditions

Please find attached the required paperwork to initiate services for [~ClientName~], which must be completed and returned at least 48 hours prior to your scheduled appointment. Should you have any questions regarding these documents, you may reach out to us via email at contactus@jonesccta.com or by phone at 817-453-2400. Please keep in mind, if you do not submit your documents as requested, your appointment will be cancelled, and you will be due a fee of *$65.00. If you need to cancel your appointment for any reason, you must do so with no less than 48 hours advance notice.

We look forward to working with you,
JCCTA Staff


*By completing either the attached ACH on File or Credit Card on File form, you acknowledge the associated account will be charged the aforementioned $65.00 if you fail to complete your documents as required or do not present for your session by the scheduled start time. Thank you for your understanding.

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Date: I have read and I agree to the

Electronic Signature of Client or Legal Guardian:

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JCCTA

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

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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JCCTA

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

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)

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JCCTA

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

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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JCCTA

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

Driver License Front
                                                                    

Ins Card Front
                                                                    

Driver License Back
                                                                    

Ins Card Back
                                                                    

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JCCTA

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

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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Notes

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Add Card Details

Card Holder Name:

Card Type:

Card Number:

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

JCCTA

604 Strada Circle Mansfield TX 76063-3201817-453-2400

PRIMARY CLIENT INFORMATION

PARTNER INFO

PRIMARY INSURED

Primary Insurance Information

SECONDARY INSURED ("If Applicable")

JCCTA

604 Strada Circle Mansfield TX 76063-3201817-453-2400

JCCTA

604 Strada Circle Mansfield TX 76063-3201817-453-2400

JCCTA

604 Strada Circle Mansfield TX 76063-3201817-453-2400

JCCTA

604 Strada Circle Mansfield TX 76063-3201817-453-2400

JCCTA

604 Strada Circle Mansfield TX 76063-3201817-453-2400

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400

604 Strada Circle
Mansfield TX 76063-3201
817-453-2400