New Client Intake Questionnaire- Darby Integrative Counseling

1
Your Email* This field is required.
example@example.com
2
Are we authorized to contact you at the email address above?* This field is required.
Yes
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3
Best Phone Number to Reach You At: * This field is required.Want to Schedule a Time for Your FREE Consultation? Click Here
Please enter a valid phone number.
4
Best days/times to reach you.* This field is required.
5
How did you find out about our services?* This field is required.
Google
Psychology Today
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Insurance Company (From a Website, Phone, Printed List etc)
Word of Mouth (A friend, family member, colleague etc.)- Please identify who in the "other section"
My Doctor, Therapist, Acupuncturist, Hospital, Treatment Center- Please identify who in the "other section
Other
6
Client's Legal First and Last Name* This field is required.
First Name
Last Name
7
Optional: Client's Preferred Name/Nickname:
8
Client's Legal Sex:* This field is required.
Male
Female
Non-Binary
Other
9
Client's Date of Birth* This field is required.
Date
Month
Day
Year
10
Client's Legal Postal Address: (Street Address, City, State, Zip Code):* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
What is the reason(s) for seeking treatment:* This field is required.
12
Are you open to sessions via:* This field is required.
Telehealth
In-Person
Both
Other
13
If telehealth, what state(s) will you be in for sessions* This field is required.
California
District of Columbia
Maryland
Virginia
Other
14
Yes
No
15
Preference for One of Our Expert Therapists?
I WANT TO SKIP THIS SECTION
Executive Director and Expert Therapist -Andrew P. Darby, LCSW-C, LCSW (He, Him)
Expert Therapist - Thomas D. Williams, NCC, LPC, LCPC, CAC II, Gottman- II (He/Him)
Expert Therapist -Lori Flick, LCPC, EMDR-Trained, CCTP II (She, Her)
Expert Therapist - Robert "Bobby" Alexander, LMSW, EMDR- Trained, IFS Informed (He, Him)
Expert Therapist - Victoria "Vickie" Norris, LCPC, EMDR-Trained (She, Her)
Expert Therapist - Kate Salmon, LPC (She, Her)
Expert Therapist - Monique Keene-King, M. Ed., LCPC, NCC (She, Her)
Expert Therapist - Andrew Flurer, LGPC- (He, Him)
Expert Therapist -Riley Cohen, LGPC (He, Him, They, Them)
16
Interested in a Support or Therapy Group?Openings Available in:
I WANT TO SKIP THIS SECTION
Yes: Learning to Manage Family Dynamics and Boundaries - Virtual AND In-Person!
Yes: Contemplating Your Relationship with Substances - Abstinence and Harm Reduction Strategies - Virtual
Yes: Political Stress- Finding Your Ground in Difficult Times - Virtual
No
17
Have you ever been in therapy before? What was your experience like, and what kind of therapy works best for you?
18
Your Pronouns:
19
Your Gender Identity:
Cis-Female
Cis-Male
Non-Binary
Gender Queer
Transwoman
Transman
Prefer not to say
Other
20
Your Sexual Orientation:
Heterosexual
Lesbian
Gay
Bisexual
Queer
Asexual
Other
21
Your Race & Ethnicity:
Black or African American alone, Non-Hispanic
White alone, Non-Hispanic
Latinx alone, Non-Hispanic
Hispanic alone, Non-Latinx
American Indian and Alaska Native alone, Non-Hispanic
Asian alone, Non-Hispanic
Native Hawaiian and Other Pacific Islander alone, Non-Hispanic
Some Other Race alone, Non-Hispanic
Multiracial, non-Hispanic
Other
22
Your Spirituality and/or Religion :
23
Your Insurance Provider?
I WANT TO SUBMIT MY FORM
Blue Cross Blue Shield (Carefirst, Federal Employee Program, BCBS of any state, etc)
United Behavioral Health or Government Employees Health Association (GEHA)
Cigna
Aetna
Medicare or Medicaid
No Insurance
Other
24
Insurance: ID Number and Group Number
25
OPTIONAL: Attach a picture of your Insurance Card (front and back):Want to be provided a cost estimate for services? Upload your insurance card and we will do the rest!
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Max. file size: 10.6MB
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I understand Darby Integrative Counseling is an Out of Network Practice:Have Insurance Questions? Click Here to Schedule a FREE Call! Ask about ThrizerPay for Costs are as low as your coinsurance! We make expert therapy affordable with Thrizer.com. Superbills submitted for you! Quick, easy, & understandable insurance info. Reimbursements DIRECTLY submitted to your bank account.
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I understand and have no insurance questions.
I have questions I will ask on the Free Consultation call.
Cost estimate for services provided during your FREE phone consultation.
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