New Client Survey
Thank you for considering Crescent Counseling Center for your mental health needs! All prospective clients are REQUIRED to complete this questionnaire in order to proceed. We appreciate the urgency of your need to be seen, and this form allows us to assess your unique needs and match you with a therapist accordingly. As such, please answer all questions to the best of your ability. After submission, you will be contacted within 1-2 business days to either schedule an initial intake, be placed on our waiting list, or you will be provided with referrals for other providers to best meet your needs.
Disclaimers/Consent
Disclaimer: If you believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this form. Instead call 911 or go to your closest emergency room.
I acknowledge that this request is not an emergency or urgent matter. I wish to proceed.
*
Yes
I acknowledge that when I have therapy sessions, whether in person or virtually, I must be located in Virginia.
*
Yes
Location Information:
Crescent Counseling Center is located in the Franconia/Kingstowne area of Alexanria. Our current address is: 6400 Grovedale Dr., Suite 200 Alexandria, VA 22310. We offer both in-person and virtual sessions.
I acknowledge that all in person sessions will be located at: 6400 Grovedale Dr. Suite 200 Alexandria, VA 22310
*
Yes
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Demographics
If the client is over the age of 18, please have them complete this form. All contact information should be direct to the client.
Full Name
*
First Name
Last Name
Relationship to Client
*
Self
Parent/Guardian
Family Member (not a legal guardian)
Other
Client Name
First Name
Last Name
Email Address
*
example@example.com
Client Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Preferred Method of Contact
*
Phone
Email
Either
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How did you find us?
How did you hear about Crescent Counseling Center?
Referred by a Friend
Referred through Insurance Provider
Social Media
Crescent Counseling Center Website
Psychology Today
Other
Comments:
(ex: Individual who referred you, details on how you found us)
Have you participated in services at Crescent Counseling Center in the past?
*
Yes
No
To your knowledge, do you have any family members currently participating in therapy at Crescent Counseling Center?
*
Yes
No
Details/Comments:
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Insurance Information
Please note: insurance can only be accepted by residents of Virginia. Crescent Counseling Center is not in network with any Medicare, Medicaid, or Johns Hopkins plans. *** Please note we do not accept EAP through Cigna. If Medicare is your primary insurance you will have to pay out of pocket and a submit a Superbill to them for reimbursement.
Insurance Provider:
*
Cigna
BlueCross Blueshield (BCBS)
Tricare (Prime)
Tricare (Select)
Out of Network/Self Pay ($225 for an intake session, $175 for a 50 minute session)
Please provide your Benefits number (Tricare) or Member ID (Cigna/BCBS):
For Tricare, sponsor SSN or the benefits number that ends with -00, -01, -02, etc
Comments:
Please note that all of our clinicians accept Cigna, BCBS, and Tricare insurance. For Cigna plans, are not an EAP provider at this time.
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Clinical Details/Client History
I am interested in...
Individual Therapy (Adult)
Individual Therapy (Child)
Applied Behavior Analysis (ABA) Services
Couples Counseling
Family Counseling
Medication Management
I'm unsure and would like to be matched with the correct service for me
Partner/Spouse Full Name
First Name
Last Name
Partner/Spouse DOB
-
Month
-
Day
Year
Date
Partner/Spouse Email
example@example.com
Presenting Concerns: Please let us know why the client is seeking outpatient therapy at this time
*
Is the client working with any other providers at this time in order to address the presenting concerns listed above?
*
Ex: Psychiatrist, Occupational Therapist, Substance Abuse Treatment
In the past year, I (the client) have experienced: (please check all that apply)
*
Disordered Eating (bingeing, purging, and or anorexia)
Suicidal Ideation
Suicidal attempt
Substance Abuse Treatment
Oppositional or Aggressive Behavior
Violent behavior
Thoughts of harming others
None of the above
Have you been hospitalized in the past year for mental health related concerns?
*
Yes
No
If applicable, please provide detail on the selections above:
Does the client have any current or past mental health diagnoses?
*
If yes, please list
Is the client currently on any medications?
*
If yes, please list
Is the client seeking an evaluation or written letter for legal or employment purposes?
*
Yes
No
If yes, please explain:
If the client is a minor, do all legal guardians consent to services?
*
Yes
No
N/A, is over 18 years old
Please disclose any custody arrangements or disputes, if applicable:
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Preferred Clinicians
Please note: all of our clinicians accept Tricare, BCBS, and Cigna insurance.
Preferred Clinicians:
*
First available
Sally Valerio
Nazanin Altamirano
Sierra Thorpe
Diamond Allen
Michelle Linnebur
Summer Lynn Malaguerra
Brian Yeagley
Rebecca Ryberg
Kelsey Keane
Carolina Rovira
Taylor Putzu (virtual only)
Amanda Sheffey (virtual only)
Lauren Mullinax (virtual only)
Avery Allen
Jessica Taylor
Shannon Dufour
Maria Afordakos (virtual only)
Kaitlyn Zito
Julia Pisani
Nicole Wiederholt
Bobbie Graham
Elizabeth Parola
Amy Rueffert
If the clinicians I selected above are not available, I am open to being matched with another clinician based on my background/goals:
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Yes, I am open to other clinicians at the practice
No, I am only interested in proceeding with the clinicians I selected above
I would like to meet with a clinician:
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In person
Virtually
Open to Either
Availability/Schedule
I am typically available...
*
Any Day
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
at....
*
Any Time
Early Mornings (7-9)
Daytime (10-2:30)
Afterschool (3:30pm or later)
Evening only (5pm or later)
Please select any and all times you are available to attend therapy sessions. Sessions are 50 minutes in length and occur on a repeating weekly or biweekly schedule
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any time
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
6:00pm
7:00pm
*Although not common, some clinicians occasionally open up weekend appointments
*
Yes, please contact me if a weekend appointment opens up
No, I am not interested in weekend appointments
Please feel free to provide any additional details about your schedule/availability that you would like us to know:
Ex: "I can do 3:30 or later on MWF, but any time on Tuesdays," "I can attend a 12pm appointment virtually"
I have answered the questions in this form honestly and accurately.
*
Submit
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