Turner Professional Group

Welcome to

NEW CLIENT PAPERWORK

We hope the following information will help make your first appointment productive and maximize the time for you to discuss your clinical situation.

Your First Visit

Making your first visit smooth and successful

1. Remember, you can download electronically to print and review, or ask for a complete set of Turner Professional Group Privacy Policies.
2. Your therapist will review and answer any questions about this paperwork or other matters.
3. Please bring your authorization number, if given to you by your insurance company, as well as your insurance card.
4. We will need information about your copayment and/or deductible. If you do not know this information, please contact your insurance company and ask for an explanation of benefit coverage for mental/behavioral health issues.
5. We will need your primary care physician’s name and telephone number.
6. If you have seen a counselor or psychiatrist within the last two years, we will need names and telephone numbers to contact them.
7. It is very helpful for the therapy process if you bring a list of goals for therapy. This will help you and your therapist make the best use of your time.

Paperwork

We recommend you download, print, and bring the following documents to your appointment.

1. Financial Agreement
2. Privacy Policy - HIPPA
3. Consent for Treatment, General
4. Medical History
5. Office Policies and Procedures

Registration Form

My Therapist

First Name*:

Last Name*:

Address*:

Apt/Suite:

City*:

State*: ZIP*:

Use my home address as my primary address, please.
Use alternative address as primary address for billing and other correspondence.

Alternative address (fill this out if you checked for alternative address):

Address:

Apt/Suite:

City:

State: ZIP:

Email*:

Home Phone:
I can be contacted at this number. A message can be left.

Work Phone:
I can be contacted at this number. A message can be left.

Mobile Phone:
I can be contacted at this number. A message can be left.

My Contact Preferences Email Mail Home Phone Work Phone Mobile Phone

Demographics

Today's Date:

Date of Birth:

Your Age Today:

Level of Education:

Ethnicity:

Gender:

Religion:

Relationship Status:

Sexual Orientation:

Children

1. Name: Age:

Gender: Male Female Live at home: Yes No

2. Name: Age:

Gender: Male Female Live at home: Yes No

3. Name: Age:

Gender: Male Female Live at home: Yes No

4. Name: Age:

Gender: Male Female Live at home: Yes No

Spouse / Partner

Name:

Length of time together:

Gender: Male Female

Age:

Occupation:

Fill out address and phone number information if different from yours:

Address:

Apt/Suite:

City:

State: ZIP:

Phone:

Employment Information

Occupation:

Company:

Work Phone:

Alternate Phone:

Method of Payment Cash Insurance Credit Card PayPal Other

Client's Insurance Information

Name of Insured:

Date of Birth:

Relationship to Insured: Self Spouse Other

Primary Insurance Company:

Insurance Billing Addess:

How you found us:

Referral Information

Referred by:

Relationship:

Im Here for the Following

Stress/Anxiety/ Fear
Infertility
Affair or Infidelity
Job Related
Sex Addiction/Compulsive Sexual Behavior
Pre-Marriage Counseling
Sex Education
Self Esteem/ Confidence
Anger
Grief/Loss
Dating Challenges
Gender Issues
Coming Out as Gay, Lesbian, Bisexual, Transgendered
Intersexuality
Addiction/ Recovery
Sexual Trauma, Abuse, Incest

Parenting
Behavioral Therapy for my child with disabilities
Divorce Negotiations
Relationship Communication
Restore/ Enhance Sexual Intimacy
Differing levels of sexual desire
Orgasm Difficulty
Arousal Difficulty
Rapid Ejaculation
Delayed/ Inhibited Ejaculation
Impotence or Erectile Dysfunction
Painful Intercourse or Dyspareunia
Inability to have vaginal penetration or Vaginismus
Sexual performance anxiety
Menopause
Other

When did these concerns begin?

Your check on the following items is considered an electronic signature

I have viewed the following:
"Welcome" Video
“Why Consider Therapy” Video
"Your First Visit” Video
"Therapy Tips” Video

I have read the following:
*Financial Agreement
*Privacy Policy – HIPPA
*Consent for Treatment, General
*Medical History
*Office Policies and Procedures

Things I'd Like to Hear About

Tell us what subjects below you're particularly interested in. We'll make sure to keep you informed on the latest developments at Turner Professional Group.

Parenting Classes
New Adult Sexual Aid Arrivals at Sante our online boutique
Relationship Enhancement
Corporate Wellness
Fun-filled, Edu-tainment Classes
Couples Retreats
Community /Agency Training

Keep me in the loop

Every now and then, we'd like to send you news about special offers and new products from Turner Professional Group. But it's all up to you, and you can change your mind at any time.

Yes, please sign me up for TPG email newsletters.

Yes, please notify me of upcoming TPG seminars or classes.

If you would prefer not to receive TPGNews, (Turner Professional Group's tip-packed monthly newsletter), practice updates and workshop announcements, please UNcheck these boxes. (Don't worry, TPG never shares its mailing list and has a strict privacy policy.)

If you are a couple or family coming to therapy, each member needs to complete this form. Thank You.

If you are unable to complete these forms prior to your session, please plan to arrive early to complete this task. All necessary paperwork must be completed prior to your therapist beginning with you. This may mean that you utilize part of your session time for paperwork, however, please note that we are unable to extend your session and it will end on time. For this reason we highly encourage that you manage your time accordingly to complete all required paperwork.

4010 Washington Street, #405 Kansas City, MO 64111 phone: (816) 931-8255 fax: (816) 931-1874
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