K. Knight Counseling Inquiry Form

K. Knight Counseling Inquiry Form

Welcome and Thank You for Reaching Out! We’re so glad you’ve taken this important step toward seeking counseling services. Our goal is to support you in the best way possible.To begin, please provide some key information about yourself by completing this form. This will help us match you with a therapist based on your needs, availability, and insurance. If we’re unable to meet your needs at this time, we will provide you with a referral to a trusted provider who can.As part of the process, we’ll need your insurance information (if applicable) to verify coverage and inform you of any copays or deductibles. We also ask for a brief description of why you’re seeking counseling to ensure we pair you with the best fit.All information you provide is strictly confidential and will only be used for insurance verification and therapist matching purposes.We look forward to connecting with you and helping you determine the next steps on your journey to wellness.
Name*

First NameLast Name
Email*
example@example.com
What are your pronoun preferences:*

He/HimShe/HerThey/Them
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Where are you located?*

NYGANJCTOther
Do You Have Insurance?*

YESNO, I will be a self-pay client (we will contact you to discuss our rates)
If yes, is this plan through an employer or place of employment?*

YESNO
If you have insurance, which plan do you have?

BCBS (Blue Cross Blue Shield or Empire BCBS)AnthemFed BlueCignaCigna- EAP (please provide your Cigna member ID below)AetnaUnited HealthcareOxfordNYSHIP (New York State Health Insurance Plan)Empire Plan (Not Empire BCBS)OscarEmblem - GHI (City employee)Emblem - GHI (NON city employee)Emblem - HIP1199NYS Marketplace or Healthcare exchange planMedicaid/Medicare (BCBS Medicaid, Fidelis, Healthfirst etc)Northwell/MagnacareOther
Insurance Member ID# (please provide, even if you are using your EAP)
Insurance Group# (if applicable)
Please upload a copy of your insurance card (Front)

Cancelof
Please upload a copy of your insurance card (Back)

Cancelof
EAP CLIENTS, how many sessions have you been approved for?
EAP CLIENTS: Please upload a copy of your EAP authorization form here

Cancelof
IF YOU HAVE ANY PROBLEMS UPLOADING DOCUMENTS , you can email copies to: admin@kknightcounseling.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If client is a minor, please provide Parent/Guardian info below:

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guradian Phone Number
Please enter a valid phone number.
When is the best time to reach you?
How did you hear about us?

Psychology Today DirectoryTherapy for Black Girls DirectoryClinicians of Color DirectoryInternet Search/WebsiteReferred by a friendOther
What Days and Times are you available for counseling?
Are you experiencing any of the following currently:

AnxietyDepressionPTSDOverwhelming stressADHDSelf Harm Acts/Suicidal thinking or attemptsOther
Are you experiencing a mental health crisis?

If you are experiencing suicidal thoughts or behaviors, or are in any type of mental health crisis, please contact 911 or go to the nearest emergency room immediately. For urgent mental health support, you can also call or text the Suicide & Crisis Lifeline at 988 to connect with a trained counselor 24/7.Your safety and well-being are our top priority. This form is not monitored for emergencies.
Tell us 1-2 sentences why you are seeking counseling at this time?
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