K. Knight Counseling Inquiry Form
Welcome and Thank you for reaching out to our practice. We are so happy that you have taken the first steps in seeking counseling services and hope to serve you in the best way possible. Please take a moment to provide some important information about yourself. By submitting this form you will begin the process of having a therapist assigned to you (depending on your needs, availability and insurance). If we cannot meet your needs at this time, we will provide you with a referral to other offices who might better serve you. To begin, we will need to know your insurance information (If applicable), so we can verify that we take it and provide you with information on your copays or any deductibles. We will also need to know a little bit about why you are seeking counseling at this time. ***ANY INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL AND IS ONLY USED TO VERIFY INSURANCE AND MATCH YOU WITH A THERAPIST WHO CAN BEST SERVE YOU. We look forward to speaking with you and at that time, we will figure out what the next best steps should be.
Name
First Name
Last Name
What are your pronoun preferences:
He/Him
She/Her
They/Them
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When is the best time to reach you?
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
If client is a minor, please provide Parent/Guardian info below:
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guradian Phone Number
Please enter a valid phone number.
Where are you located?
NY
GA
NJ
CT
Other
Do You Have Insurance?
YES
NO, I will need to be a self-pay client (we will contact you to discuss our rates)
If you have insurance, which plan do you have?
BCBS (Blue Cross Blue Shield or Empire BCBS)
Anthem
Fed Blue
Cigna
Aetna
United Healthcare
Oxford
NYSHIP (New York State Health Insurance Plan)
Empire Plan (Not Empire BCBS)
Oscar
Emblem - GHI (City employee)
Emblem - GHI (NON city employee)
Emblem - HIP
1199
NYS Marketplace or Healthcare exchange plan
Medicaid/Medicare (BCBS Medicaid, Fidelis, Healthfirst etc)
Northwell/Magnacare
Other
Insurance Member ID#
Insurance Group# (if applicable)
Is this plan through an employer or place of employment?
YES
NO
IF YOU HAVE INSURANCE, please email a photo of your insurance card (front and back) to: admin@kknightcounseling.com
How did you hear about us?
Psychology Today Directory
Therapy for Black Girls Directory
Clinicians of Color Directory
Internet Search/Website
Referred by a friend
Other
What Days and Times are you available for counseling?
Are you experiencing any of the following currently:
Anxiety
Depression
PTSD
Overwhelming stress
ADHD
Self Harm Acts/Suicidal thinking or attempts
Other
Tell us 1-2 sentences why you are seeking counseling at this time?
Submit
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