New Client Inquiry

1

What brings you to Growing Well Counseling?* This field is required.Reason for seeking therapy (check all that apply)

Contemplating family planning

Pregnancy or Infant Loss

Infertility

Perinatal Sexual Health

Prenatal mental health

Postpartum Mental health

Birth trauma

Other

2

Who referred you or how did you find us?We won't acknowledge a referral without your permission!

3

Name* This field is required.

First Name

Last Name

4

Email* This field is required.

example@example.com

5

Phone Number* This field is required.

Please enter a valid phone number.

6

Location* This field is required.City, State

7

What type of insurance do you have?* This field is required.Please list insurer (Anthem, Aetna, Cigna United etc)

8

Telehealth or In Person Counseling?* This field is required.Which type of care would you prefeer

Telehealth-only

In Office Only

Either, I just want a specialist!

Possibly both

9

Are you requesting a specific therapist?Please note any provider preferences (person, telehealth/in person, first available)

10

What is your availability for therapy?* This field is required.Flexible, after or before certain time(s), certain days. Most of our therapists work Weekdays 9-3

Flexible, after or before certain time(s), certain days. Most of our therapists work Weekdays 9-3

11

Current Treatment: Are you in therapy* This field is required.currently seeing a therapist

YESNO

12

Describe current therapywhere and with whom? how recently?

13

Are you on any medication for mental health?* This field is required.Prescribed or supplements

YESNO

14

Which medications?list any medications, supplements you're taking for mental health and who is prescribing

15

Please List Current Provider(s)* This field is required.OBGYN, midwife, primary care, naturopath- anyone currently providing you care

16

What else would you like us to know?* This field is required.Share any details you think would be helpful.