Name
*
First Name
Last Name
Guardian's Name
For clients under 18 (skip if self)
First Name
Last Name
What type of therapy?
*
Client Date of Birth
*
MM
DD
YYYY
Phone
(###)
###
####
Email
*
How did you hear about us?
*
Insurance Provider
*
Aetna
EAP Aetna
Anthem Blue Cross Blue Shield
EAP Blue Cross Blue Shield
Cigna
EAP Cigna
EAP McLaughlin Young
EAP Optum Behavioral Health
EAP Workplace Options/Deer Oaks
United Healthcare
Tricare
Self-Pay
AmeriHealth
Medicaid
Have you received mental health treatment before?
*
No, this is my first time.
Yes, I have attended therapy or counseling in the past.
Yes, I have been hospitalized for my mental health.
Have you felt like harming yourself or harming others in the past 2 weeks?
*
Do you currently take any medications for your health?
Yes
No
If you answered 'yes' to the question above, what does the medication treat? (If No, please type N/A)
Would you like to be seen in-person or virtually?
You may select both if unsure or open to either option.
Therapist Preferences
Are you open to working with a therapist in training?
*
Would you like to request a specific therapist?
Requests do not guarantee that the therapist requested will be able to take your case.
