become a client

Is the prospective client or a family member a current or previous client of McGinnis Behavioral? *

No

The prospective client has been seen by Dr. McGinnis in the past

The prospective client has been seen by Cara Shapiro in the past

A family member is a current client

A family member is a previous client

Prospective Client's Name *

If a family, the identified client is a child.

First Name

Last Name

Prospective Client's Date of Birth *

MM

DD

YYYY

Prospective Client's Sex *

Male

Female

Responsible Party's Name *

This person accepts full financial responsibility for services.

First Name

Last Name

Your Phone Number *

(###)

###

####

Prospective Client's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is the primary language spoken in the home? *

English

Spanish

Other

Do you have a preference as to clinician? *

Chris McGinnis, PhD, BCBA-D

Cara Shapiro, MS, BCBA

No preference

Is the prospective client currently being seen by a psychiatrist? *

Yes

No

Is the prospective client currently taking medication? *

Yes

No

Is the prospective client currently being seen by another mental health therapist? *

Yes

No

If so, does that therapist know about, and agree, with your decision to seek these services? *

Yes

No

Not applicable

Is the prospective client diagnosed with an autism spectrum disorder? *

No

Suspected but not yet diagnosed

Yes, mild ASD/Aspergers, "Level 1"

Yes, moderate ASD, "Level 2"

Yes, severe ASD, "Level 3"

Is there a history of suicide attempts? *

Yes

No

Is the prospective client using illicit drugs or abusing prescription drugs? *

Yes

No

Is the prospective client exhibiting an eating disorder like anorexia or bulimia? *

Yes

No

Is your family in the midst of divorce? *

Yes

No

Is there currently a protective/restraining order in place against anyone in the family? *

Yes

No

If for a child, do all legal guardians believe McGinnis Behavioral represents the best next step? *

Yes

No

We have no children at this time/Prospective client is an adult

May we contact you via text (for other than appointment reminders)? *

(Recommended)

Yes

No

May we leave voicemail messages? *

Yes

No

What are the most reliable ways of reaching you? *

(check all that apply)

Text

Email

Phone

Are you or your spouse active military? *

Yes

No

Are you or your spouse a first responder? *

(police officer, EMT, paramedic, firefighter)

Yes

No