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Chad
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Congo
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Cote d'Ivoire
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9
Are you a current or previous client of Forward Counseling?
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Current clients can reach out to the front desk directly for scheduling.
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Are you the client?
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Current clients can reach out to the front desk directly for scheduling.
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Legal Name of Client
We must schedule directly with all clients ages 18+. If you are reaching out on behalf of a loved one, we are happy to answer any questions.
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Client's Age
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We have providers who work with clients ages 2+!
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Client's Date of Birth
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14
Which of the following do you feel like apply to you/the client?
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The information in this form is confidential.
Depression
Treatment Resistant Depression (you have tried 2+ SSRI's without remission)
Relationship difficulties
Anxiety
Grief
Trauma
Stress
Mood disorder
Personality disorder
LGBTQ+
Drinking too much alcohol
ADHD
Behavioral Issues
Unhealthy habits
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Tell us a bit more about what brings you in!
We strive to pair our clients with the perfect fit, the first time. Tell us your goals, the type of person you want to work with, and any other information you think will help us pair you with the most fitting provider.
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Have you had a recent hospitalization or rehabilitation?
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Do you have a preferred office location?
Leave blank if no preference!
Memphis, Tennessee
Jackson, Tennessee
Nashville, Tennessee
Knoxville, Tennessee
Mississippi
Telehealth/Online
Germantown, Tennessee
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Which services are you interested in?
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We are happy to help you decide which services may be best for you!
Individual Therapy
Couples Therapy
Family Therapy
Psychiatric/Medical Evaluation or Medication Management
Trauma Therapy
Executive, Business and Life Coaching
Speech and Language Therapy
Spravato (Esketamine) for treatment resistant depression
LENS Neurofeedback for brain health
The Sinclair Method for elimination of alcohol cravings
EMDR
I'm not sure
Other
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Primary Insurance Company
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We currently cannot accept any EAP, Medicare or Amerigroup plans- including dual or secondary insurance plans. We do offer affordable self pay sessions!
I am paying out of pocket/ not using insurance
Aetna
American Behavioral
Anthem BCBS
Blue Cross Blue Shield (commercial)
Champ VA
Cigna
Evernorth
First Responders Insurance
Humana
Magellan
Meritain
Optum
Tenncare United Community
Tenncare Bluecare
Tricare
UMR
United Healthcare
VA Community Care Optum
VA Community Care Triwest
Workman's Comp
Other
I am paying out of pocket/ not using insurance
Aetna
American Behavioral
Anthem BCBS
Blue Cross Blue Shield (commercial)
Champ VA
Cigna
Evernorth
First Responders Insurance
Humana
Magellan
Meritain
Optum
Tenncare United Community
Tenncare Bluecare
Tricare
UMR
United Healthcare
VA Community Care Optum
VA Community Care Triwest
Workman's Comp
Other
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20
What is your gender as listed on your insurance policy?
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21
Insurance Subscriber ID or Member Number
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If you are using insurance, we need this information up front to get you scheduled. Forward Counseling does not accept secondary insurance or file claims for it.
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Insurance Group Number
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If you are using insurance, we need this information up front to get you scheduled.
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23
Are you the primary insurance policy holder?
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Let us know if you or a family member are the insurance policy holder.
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24
Name of Primary Insurance Holder
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Please provide your legal name as used on your insurance card.
First Name
Last Name
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25
Insurance Holder Information
*
This field is required.
If you are using insurance, we need this information up front to get you scheduled, just to bill insurance. Your session information is private and HIPAA compliant. Also, Forward Counseling does not accept secondary insurance or file claims for it.
Insurance Holder's Billing Address
Insurance Holder's Email
Insurance Holder's Phone Number
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Male
Female
Please Select
Please Select
Male
Female
Insurance Holder's Gender
Insurance Holder's Date of Birth
Relationship with Insured
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Copy of Medical Insurance Card
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Please provide a front and back snapshot of your medical insurance card so that we may more easily confirm your insurance eligibility.
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What is your availability for sessions?
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We value your input.
Whenever, I can be flexible.
Mornings
Afternoons
Evenings
Weekends
Weekdays
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28
Do you have a preferred provider?
NONE
Angelik Sims, Life coach
Anthony Black, MSW
Ashley Householder, PreLicensed MFT
Ashley Jones Buck, LPC-MHSP
Ben Leven, PMHNP
Bianca Loyd, Intern counseling
Branden Brown, MFT
Cathi Moore, LCSW
Cinda Gee, LPC-MHSP
Cynthia Slover, LPC-MHSP
D'Lessia Wedley, LMFT
Dean Graves, Life Coach
Denice Perkins, MA, SLP
Devonne George, Intern counseling
Dominique Braden, LMFT
Dr. Richard Wanderman, MD
Elizabeth "Liz" Ferzacca, LMSW
Elizabeth Welwood, LPC-MHSP
Erica Dawkins, LPC-MHSP
Greg Hale, LPC-MHSP
Janet Hardy, LPC-MHSP
Jeannie Wilkins, PMHNP-BC
Jelisa Anderson, LPC
Jenny French PreLicensed MS
Joy Hutchinson, PreLicensed
Kandis Randle
Karen Grossman, LCSW
Karen Wade, PreLicensed MSW
Lauren Baker, PreLicensed MSW
Lauryn Murphy, PA
Leandra Mayfield
Lesley Rickman, LMSW
Meredith Sachs, LPC-MHSP
Michael Valdes, LCSW
Nakicia Smith, LCSW
Natasha Schwinn, LPC-MHSP
Pratik Patel, LPC-MHSP
Rachel McCullough, LMFTA
Rasheedah Jackson, PreLicensed CMHC
Ricci Hellman, LPC-MHSP
Robert Gurich, LPC-MHSP
Sarah Rather, PreLicensed, MS
Shae Pugliese, Intern mft
Tiffany France, LPC-MHSP
Tristan Mckenzie, PreLicensed MS
Vaniessa Jones, PreLicensed MS
William Rickman, LENS TECH
Other
NONE
Angelik Sims, Life coach
Anthony Black, MSW
Ashley Householder, PreLicensed MFT
Ashley Jones Buck, LPC-MHSP
Ben Leven, PMHNP
Bianca Loyd, Intern counseling
Branden Brown, MFT
Cathi Moore, LCSW
Cinda Gee, LPC-MHSP
Cynthia Slover, LPC-MHSP
D'Lessia Wedley, LMFT
Dean Graves, Life Coach
Denice Perkins, MA, SLP
Devonne George, Intern counseling
Dominique Braden, LMFT
Dr. Richard Wanderman, MD
Elizabeth "Liz" Ferzacca, LMSW
Elizabeth Welwood, LPC-MHSP
Erica Dawkins, LPC-MHSP
Greg Hale, LPC-MHSP
Janet Hardy, LPC-MHSP
Jeannie Wilkins, PMHNP-BC
Jelisa Anderson, LPC
Jenny French PreLicensed MS
Joy Hutchinson, PreLicensed
Kandis Randle
Karen Grossman, LCSW
Karen Wade, PreLicensed MSW
Lauren Baker, PreLicensed MSW
Lauryn Murphy, PA
Leandra Mayfield
Lesley Rickman, LMSW
Meredith Sachs, LPC-MHSP
Michael Valdes, LCSW
Nakicia Smith, LCSW
Natasha Schwinn, LPC-MHSP
Pratik Patel, LPC-MHSP
Rachel McCullough, LMFTA
Rasheedah Jackson, PreLicensed CMHC
Ricci Hellman, LPC-MHSP
Robert Gurich, LPC-MHSP
Sarah Rather, PreLicensed, MS
Shae Pugliese, Intern mft
Tiffany France, LPC-MHSP
Tristan Mckenzie, PreLicensed MS
Vaniessa Jones, PreLicensed MS
William Rickman, LENS TECH
Other
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Credit/Debit Card Information
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