Initial Consultation Pre-Screening Form
This form will be sent to the therapist scheduled for consultation to review with you at the time of consultation.
Person Completing Form
*
Please Select
Jazz, MSW Student, Admin
Hallae, BSW Intern
Tannii, BSW Intern
Brittney, MSW Intern
Client is self-completing.
Demographic Information
Name of Potential Client
*
First Name
Last Name
Name of Parent Completing Form for Clients
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Potential Client Email
*
Please enter your email address
Potential Client Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
For couples: Spouse or Partner Name
First Name
Last Name
Spouse or Partner Phone Number
Please enter a valid phone number.
Spouse or Partner Email
example@example.com
State of Residence. HBWC Clinicians are only allowed to provide services to clients in the state in which they are licensed. Student Clinicians are able to provide services in each state their supervisor is licensed in.
Texas
Mississippi
Tennessee
How client hear about us?
*
Please Select
Therapy for Black Girls
Mental Health Match
Google
Psychology Today
Word of Mouth (Previous Client, Current Client, Physician, Community Member, etc)
Therapy Den
Open Path Collective
Insurance Company Directory
Community Event
Alma Directory
Clinicians of Color
Potential client is a previous client.
If other, please list referral source.
What is your preferred method of contact?
*
Phone Call
Text Message
Email
Self Pay, Insurance (Approved Insurances), Equitable Therapy Program, EAP
*
Self Pay
Accepted Insurance (Upload Photos of Insurance Card to Client Portal)
Equitable Therapy Program **Clients with Medicaid/Medicare Only with an intern
Employee Assistance Program (Optum EAP, Cigna EAP, Magellan EAP, Lyra EAP)
If using Employee Assistance Program benefits for free therapy sessions, client must email a copy of the authorization code that includes total # of sessions authorized and the dates of the authorization. To find out if you have EAP benefits, call your HR department of your employer.
Optum EAP
Cigna EAP
Magellan EAP
Lyra EAP (Does not require the email)
No EAP
What is the client's availability to engage in therapy sessions? Please select all that apply.
*
Day M-F 8-4
Evening M-F 4p-8p
Night M-F after 8pm
Weekend Morning
Weekend Day
Weekend Evening
Weekend Night
HBWC Clinicians only provide services to clients in the state in which they are licensed. Student Clinicians are able to provide services in each state their supervisor is licensed in as indicated below. If a clinician is not listed, they are not taking new clients.
Texas Residents (Virtual Only)
Nkenge Bryant, LMSW
Melanie Bennett, LMSW
KeAirra Haynes, LMSW
Keiera Ates, LCSW
Am'Breshia Davis, LMSW
Tennessee Residents (Virtual and In-Office) Office address: 5583 Murray Ave, Suite 208, Memphis, TN 38119. Can serve north Mississippi residents if in office.
Sierra Jones, MSW Grad Intern (Virtual and In-Office) WAITLIST
Kiercia Barnett, LMSW (Virtual and In-Office)
Wendi Stec, LMSW (Virtual and In-Office)
Arkansas Residents (Virtual)
Kiercia Barnett, LMSW (Virtual and In-Office)
Mississippi Residents (Virtual)
Nancy Keys, DPC, LMSW (Virtual Only)
Graduate Student Interns
Paige Wilkey, MSW Grad Intern (Virtual Only)
Stephanie Roman, MSW Grad Intern (Virtual Only)
Maria Fernandez, MSW Grad Intern (Virtual Only)
Lindsey Porter, MSW Grad Intern (Virtual Only)
Carrington Sims, CMHC Intern (Virtual Only)
Kiana Lester, MSW Grad Intern (Virtual Only)
Kimmy Lehano, CMHC Intern (Virtual Only)
Provide a brief summary of the reason client is seeking counseling.
You may view each therapist's profile at
www.honeybwc.com
Save
Submit
Should be Empty: