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Client Portal

 

Welcome to the Client Portal!

Please complete each of these items 24-hours prior to your first session.

Informed Consent Agreement

INFO: This form provides full disclosure regarding treatment, business, and legal matters at Change, Inc.  If you are under 18, fill this out twice — both you (as the client) and your parent/guardian must complete it separately.

ESTIMATED COMPLETION TIME: 20-30 mintues

NOTE: This is a legally binding agreement, and a requirement — therapy cannot begin without it.

Multi-Modal Life History Inventory (MMLHI)

INFO: This form collects essential information on you, your background, and your functioning across multiple domains in an effort to have a comprehensive current and historical picture of you. 

ESTIMATED COMPLETION TIME: 1-2 hours

Michigan Alcohol Screening Test-Revised (MAST-R)

INFO: This form contains the Michigan Alcohol Screen Test-Revised (MAST-R), a 25-question “yes/no” test that is used to help identify alcohol dependency.

ESTIMATED COMPLETION TIME: 5-10 minutes

NOTE: Clients should complete this exam whether or not they are coming to counseling for alcohol use and/or whether or not they have alcohol use issues.

Drug Abuse Screening Test (DAST)

INFO: This form contains the Drug Abuse Screening Test (DAST), a 20-question “yes/no” test that is used to help identify drug-related issues.

ESTIMATED COMPLETION TIME: 5-10 minutes

NOTE: Clients should complete this exam whether or not they are coming to counseling for drug use and/or whether or not they have drug use issues.

Release-Transfer Authorization

INFO: This form contains an authorization/release for us to communicate with anyone you designate – family, doctors, therapists, pastors, etc. –  click below and complete the online form.  Do this as many times as is necessary for all the parties with whom you wish us to communicate.  Only complete this form if there are third-parties with which you wish us to communicate.

ESTIMATED COMPLETION TIME: 3 minutes

NOTE: If you do not complete this step, we cannot talk with any outside sources, including family members.

Upload Section:

Use this to upload a headshot of yourself for your client file. If you have other items you wish for us to see, you may upload them here as well.
Drop files here or
Max. file size: 32 MB.
    Please attach whatever you'd like us to see.
    ATTESTATION/AFFIXING OF NAME AS DIGITAL SIGNATURE(Required)
    Your Name
    Your Email
    Address entered will receive a signed copy of this release.

    Supplemental Forms

    Please complete any of the following forms as necessary throughout counseling.

    Add Myself to Change, Inc. Mass Emails

    INFO: This form allows you to enter your name and email for inclusion on Change, Inc. mass emails which include important updates/changes to our policies, weather or emergency announcements, and more.

    ESTIMATED COMPLETION TIME: 30 seconds

    NOTE: You DO NOT NEED TO COMPLETE THIS if you have filled out the MMLHI and/or the Informed Consent Agreement above — you will have already been automatically updated.

    ADA Service Animal Survey

    INFO: This form allows you to enter relevant information about your ADA Service Animal.

    ESTIMATED COMPLETION TIME: 90 seconds

    NOTE: You DO NOT NEED TO COMPLETE THIS unless you have an ADA Service Animal and are planning to bring the animal to sessions at Change, Inc..

    Documentation Request:

    Do you have something you need from us regarding documentation?  Use the form below!

    NOTE: New clients should not complete this form.  Only complete this step if you have already had sessions at Change, Inc. and are subsequently requesting documentation.

    Contact Info Change:

    Do you need to update your contact information? Use the form below!  

    NOTE: New clients should not complete this form.  Only complete this step if you have already had sessions at Change, Inc. and are subsequently requesting to change essential contact information.

    Name Change Form:

    Are you making a name change and want us to know? Use the form below!  

    NOTE: New clients should not complete this form.  Only complete this step if you have already had sessions at Change, Inc. and are subsequently requesting to change your name and related information.

    ST. LOUIS COunseling Locations

    NOW IN ONE EXPANDED & IMPROVED LOCATION TO SERVE YOU BETTER!

    Change, Inc. South Hampton & 44:

    3460 Hampton Avenue, Suite 204

    St. Louis, MO 63139 

    v

    PHONE/EMAIL HOURS:

    Monday through Friday // 9a to 3p

    Saturday // 12p to 3p

    Contacts received before 3pm:

    • returned the same business day

    Contacts received after 3pm or on the Sundays:

    • returned the next business day

    314-669-6242 / 877-5-CHANGE (524-2643)

    contact@changeincorporated.org

     

    COUNSELING HOURS

    7 DAYS PER WEEK:

    10am to 9pm