New Client Form
Thank you for your interest in Kelly Counseling! Please take a moment to fill out this form so we can use your information to match you with the right clinician as soon as possible. Please add as much information as possible. If you have any questions about this, please email us Info@KellyCounselingandConsulting.com
Are you the client?
*
Yes
No
Are you interested in couple's therapy?
Yes
No
Your Information
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Relationship to the Client
*
Please Select
Parent
Partner
Sibling
Friend
Other
Client Information
Client Name
*
First Name
Last Name
Partner's Name
First Name
Last Name
Partner's Email
example@example.com
Client Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Current Age
*
Consent to Therapy
Please note that individuals aged 14 and above are required to consent to therapy. In order to share any information with a parent/guardian, they will need to sign a release of information form. Please make sure that the Client Email address belongs to the client and not to a parent/guardian.
Client Gender
*
Female
Male
Non-binary
Prefer not to say
Payment Method: How do you plan to pay for services?
*
Insurance
Self-pay
Other
Fees
Please note: Our fees are $160/session, and $190 for the first evaluation. We accept most major insurance plans, and the portion you are responsible form, if any, will be assessed after claim processing.
Insurance Information
Please Select Your Insurance or Other Payer
*
Aetna
Aetna Health Plans PPO
AmeriHealth Administrators
Blue Cross Blue Shield of Pennsylvania
Blue Cross Blue Shield of Pennsylvania Central Highmark
Blue Shield of Pennsylvania
Cigna
ComPsych
EAP
Highmark Delaware PPO
Independence Administrators
Independence Blue Cross of PA
Independent BLC of PA (Also known as Personal Choice PPO of Pennsylvania.)
Keystone Health Plan East
Medicare of PA/NJ/DE/MD
Pennsylvania Keystone Health Plan East
Personal Choice PPO / Independent BLC
Personal Choice PPO of Pennsylvania
United HealthCare
Other
Out of Network
We are out-of-network for the payer you have selected. In order to receive services, you would need to self-pay and then seek a refund from your insurance company directly.
EAP
If you have selected EAP, please provide the reference number, phone number, number of sessions covered, and covered clinician if applicable below.
Other
If you have selected Other, it is likely that we are not in-network with your insurance company. Please provide your insurance details below, and we will do our best to verify our status with your insurance company.
Payer Details: Please provide as much information about your insurance or other payer as possible.
*
Reasons for Seeking Therapy
Note: Please answer the following questions to the best of your ability from the perspective of the client.
Have you seen a mental health professional before?
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Yes
No
Are you interested in in-person or telehealth session?
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In-Person
Telehealth
Hybrid (Both In-person & telehealth)
Either mode
What type of therapy are you seeking?
*
Individual
Couple's Counseling
Family Therapy
Other
Please check any of the following you have experienced in the past six months
*
Anxiety
Decreased appetite
Depressed mood
Difficulty sleeping
Excessive sleep
Fatigue/low energy
Fear
Hopelessness
Increased appetite
Isolation from others
Low motivation
Low self-esteem
Panic
Tearful or crying spells
Trouble concentrating
Other
What brings you to counseling at this time? Is there something specific, such as a particular event?
*
What else would you like us to know?
How did you hear about Kelly Counseling?
*
Submit
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