Counseling Interest Form

Counseling Interest Form

Skip anything that does not apply to you.
Shavez Pinestraw, M.S., LPC, NCC

Location 1: Colors of Counseling & Consulting, Owner
via Virtual Counseling

Location 2: Turning Point Counseling Services
via Virtual Counseling

Work Phone: (504) 345-9154
Email: shavez@colorsofcounseling.com

Therapy Office Hours
Monday: 11 AM–5 PM;
Tuesday-Thursday: 10 AM–5 PM;
Fri-Sun: Out of Office

*All calls, texts, emails, and form submissions will be responded to within 24-48 hours.
Client Name

First NameLast Name
Client's Preferred Pronouns

Other
Person completing the form

Other
Name of The Person Completing The Form

First NameLast Name
Date of Birth

MonthDayYear
Date
Client's Relationship Status
Client's Email
example@example.com
Client's Cell Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact
Will your sessions be in person or virtual? (Only accepting virtual meetings at the moment)
Type of Counseling Service
Partner's Name

First NameLast Name
Partner's Date of Birth

MonthDayYear
Date
Partner's Email
example@example.com
Will you be using health insurance?
Partner's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Some insurances are accepted. For private pay clients and out-of-network clients, we can offer a superbill to submit to your insurance for possible reimbursement.

Our counseling rates are:
- Individual Counseling
  - $100 for intake & follow-up sessions
- Couples/Marriage Counseling
  - $125 for your first/intake session
  - $100 for all follow-up sessions
In order to provide quality mental health care to all, I also offer a few income-based sliding scale slots.
Upload a copy/photo of your insurance card (Front & Back)

Cancelof
If your insurance isn’t accepted are you interested in private pay?
Please indicate which payment option best fits your current situation.
Our sliding scale range for individual counseling is $65–$85. Please indicate if this range feels manageable for you at this time.
Our sliding scale range for couples/marriage counseling is $75–$90. Please indicate if this range feels manageable for you at this time.
Would you like to schedule your first session or a free phone consultation?
Once you submit this form, you’ll be redirected to schedule your 15-minute phone consultation.

If you don’t see any available dates for next week or if there are no dates that match your availability, please send me an email: shavez@colorsofcounseling.com
Please provide three different times and dates when you are available for a phone consultation. (e.g., Monday: Free, Friday: 8AM-11AM)
What days and times would be best for session appointments?
Please note: I am out of office Fri-Sun. Also, my hours are listed at the top of this form.
How soon are you looking to begin counseling?
(e.g., next week, as soon as possible, etc.)
Mental Health History
Why are you seeking counseling?
What do you hope to gain from counseling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
Therapist Name

First NameLast Name
Reason for seeking help with your previous therapist
Please describe any other experiences you have had problems in the past
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature
Should be Empty:

Counseling Interest Form

Mental Health History