Ashakti Initial Referral Profile

1
Today's Date
Date
Month
Day
Year
2
Is this your first time seeking services?
YESNO
3
What is your client status?
Please Select
Please Select
Current Client
Previous Client
Previously Submitted Information
4
Are you filling out this form on behalf of yourself as a client? * This field is required.
YESNO
5
Are you filling out this form on behalf of a minor that would be our client? NOTE: If so, please fill out this form with all of the information pertaining to the minor.* This field is required.
YESNO
6
What is your name? Please be sure to list your full middle name (not initial).* This field is required.
First Name
Middle Name
Last Name
7
What is your child's name (if the child is the client)? Please be sure to list your full middle name (not initial).
First Name
Middle Name
Last Name
8
What is your email address?* This field is required.
example@example.com
9
What is a cell phone number, in which we can text?* This field is required.
Please enter a valid phone number.
10
How did you hear about AW&Y?* This field is required.
Our Instagram
Our Facebook Page or Facebook Group
Our Youtube Channel
Your Employee Assistance Program (EAP) Provider
Your Insurance Provider
A Friend, Family Member, and/or Acquaintance
A Former Client of AW&Y
A Wellness Professional
Our Website
Asha Sim's Profile on Therapy for Black Girls
Asha Sims Profile on Psychology Today
Keyananna Rei Profile on Psychology Today
Other
TeleWellnes Hub
11
If you previously indicated that you heard about AW&Y through a person, please let us know the name of the individual.
First Name
Last Name
12
What type of services are you seeking?
Please Select
Individual Counseling( Adults 18 + )
Family Counseling
Couples Counseling
13
Do you have a specific therapist that you wish to see? If so please state name.
First Name
Last Name
14
How did you first contact AW&Y? Please select one.* This field is required.
This is my first contact.
You emailed our business administrative address (ashaktiwellness@gmail.com)
You emailed our wellness services inquiry address (info@ashaktiwellness.com)
Our website chat messenger at www.ashaktiwellness.com
You messaged us via Psychology Today
You called 980-202-1183
You texted 980-202-1183
You left a voicemail at 980-202-1183
You messaged AW&Y via Facebook Messenger
You commented on AW&Y's Facebook Page
You commented on AW&Y's Instagram
You direct messaged AW&Y's Instagram
You commented on an AW&Y Youtube video
You direct messaged AW&Y Youtube Channel
15
Please indicate your any AW&Y wellness service(s)/product(s)/consultation(s) interest. NOTE: ALL OFFERINGS ARE EITHER SOCIALLY DISTANCED IN-PERSON AND/OR VIRTUAL.* This field is required.
Emotional Wellness (i.e. Individual Counseling, Couples Therapy, Integrated Counseling, Psychotherapeutic Reiki, Somatic Work, EMDR, Etc.)
Physical Wellness (i.e. Detailed Holistic Medical Wellness Consultation, Detox Consultation/Detox Services, Dance, Yoga, Weight Management, Smoking Cessation Program ,Etc.)
Social Wellness (i.e. Topic-Based Support Groups, Trauma Yoga: The Healing Inside Out Program, Relationship Coaching for Friends as well as Partners, Autism & ADHD Social Skills Training, Etc.)
Spiritual/Energetic/ Wellness (i.e. Reiki, Sound Bowl Healing, Breathwork & Mindfulness, , Chakra Assessments, Chakra Clearings, Etc.)
16
Please identify other service of interest* This field is required.
The Bridges Program (Low Cost/Free Counseling with Our Graduate Interns)
Trauma Yoga Program/Neurodivergent Group/ Women’s Wellness Group
General Yoga
Wellness Supplements: Sound Bowl Therapy, Breathwork, Meditation
Other
17
What is your date of birth? * This field is required.
Date
Month
Day
Year
18
Client's Age
19
What is your administrative gender?
Female
Male
20
What is your identified ethnicity?
Hispanic/Latino
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White/Caucasian
Identified ethnicity not listed
21
How will you pay for services?* This field is required.
Please Select
Please Select
Self-Pay
Insurance
EAP
22
Type of Insurance
Please Select
Please Select
BCBS
Aetna
Cigna
United
Beacon
Optum EAP
CommPsych
Other
23
Upload Insurance Information If you plan on using insurance please upload a copy of your insurance information so that our team can verify your benefits before your consultation call. (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
24
Please indicate the severity level of your concerns.* This field is required.
Crisis
Low
Moderate
Severe
25
Please briefly explain the context of your current issues.* This field is required.
26
What is your physical mailing address? Please do not list a PO Box. * This field is required.
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
27
Although you provided your physical mailing address, due to certain licensing regulations on certain services/products/consultations we must ask, do you currently reside in the state of North Carolina?* This field is required.
YES
NO
28
Is it ok to leave a confidential message at the email listed above?* This field is required.
Yes
No
29
Is it ok to leave a confidential text message and/or voicemails at the cell phone number listed above?* This field is required.
Yes
No
30
Is it ok to receive information regarding services and programs via email from Ashakti Wellness?* This field is required.
Yes
No
31
Days of Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
32
Availability Time of Day
Morning
Afternoon
Evening
Should be Empty: