Counseling Screening
Let us help match you with one of our providers by answering the following questions
Client Name
*
First Name
Last Name
Preferred Name (if different from above)
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How Did You Hear About Us? (ex., friend, web search, doctor)
*
What Type of Counseling are You Looking for?
*
Please Select
Individual Therapy for myself
Individual Therapy for someone else
Couples Therapy (for myself and my partner)
Family Therapy
Group Therapy
Client Age
*
3-5
6-12
13-17
18-24
25-30
31-40
41-50
51-60
61-70
70+
Client Age
*
Days Available for Scheduling (pick one or more)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
I'm flexible
Best Times for Scheduling (pick one or more)
*
8-11am
11am-2pm
2pm-5pm
5pm-9pm
I'm flexible
Any Preferences for Your Therapist? (choose all that apply)
*
Male
Female
Religious based
Non-religious based
LGBTQIA+ trained
Younger than 40 years old
Older than 40 years old
Person of color
I'm flexible
How Do You Prefer to Meet for Therapy?
*
In Person/At Office
Via Phone/Telehealth
Do you have Medicaid or Medicare (including Ambetter, MO HealthNet, Healthy Blue, Golden Rule, etc.)?
*
Yes
No
Not Sure
Are You Planning to Use Insurance?
*
Yes
No
Not Sure
Which Insurance(s) are You Planning to Use? (Choose all that apply)
*
Aetna
Anthem
Blue Cross/Shield (BCBS)
Cigna
ComPsych
Coventry
HealthLink
Humana
Magellan
Optum
United Healthcare
Wellcare
Other
Please Describe
*
What Amount Seems Affordable for You to Pay (per Counseling Session)?
*
$0-$30
$30-$50
$50 or more
Other
Please Describe
*
Please briefly describe why you are seeking counseling services
*
How Do You Prefer to Be Contacted?
*
Email
Phone Call
Text
Submit
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