Referrals

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 1-3 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

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 the state of Virginia.*

Yes
Location Information:
I acknowledge that all in-person sessions will be located at: 6400 Grovedale Dr. Suite 200 Alexandria, VA 22310*

Yes

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 NameLast Name
Relationship to Client*

SelfParent (Legal Guardian)Other
Is the client a minor (under the age of 18)?*

YesNo
Please list all legal guardians of the client (Full name, email address, phone number)*
Do all legal guardians consent to services?*

YesNo
Is there a custody agreement in place?*

YesNo
Client Name *

First NameLast Name
Preferred Email Address*
example@example.com
Client Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.

Insurance Information

Please note: Crescent Counseling Center is not in network with any Medicare, Medicaid, or Johns Hopkins plans. *** Please note we do not accept EAP coverage. If Medicare or Medicaid is your primary insurance you will need to pay out of pocket and a submit a Superbill to them for reimbursement.
Insurance Provider:*

CignaBlueCross Blueshield (BCBS)United Healthcare (UHC)Tricare (Prime)Tricare (Select)Out of Network/Self Pay ($225 for an intake session, $175 for a 50 minute session)
Tricare Prime: Are you an active duty service member seeking services for yourself?

YesNo
Please provide your Benefits number (Tricare) or Member ID (Cigna/BCBS/UHC):
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.

New Client Survey