Black Brain Campaign 2024 EXPANSION

1
Have you received therapy services from BBC in the past?* This field is required.
Yes
No
2
Do you have any of the following insurances? AETNA, Highmark, Health Advocate, CIGNA or Allied Trades* This field is required.
YESNO
3
Since you answered yes to having one of the listed insurances, you do not qualify for free therapy services. Your insurance will be charged for therapy services.
4
Do you live in the state of Pennsylvania? * This field is required.
YESNO
5
We cannot service you at this time due to being outside of Pennsylvania.
6
If you received services from BBC in the past and would like to receive services at this time, you will be charged at a rate of $25 per session.* This field is required.
I Agree
7
Would you prefer In-person or telehealth?* This field is required.
Please Select
Please Select
In-person
Telehealth
Hybrid
8
Select Location* This field is required.
Please Select
Please Select
West Philly, 5429 Chestnut Street
Murphey's Market - 7408 West Chester Pike, Upper Darby PA 19082
9
When are your available to meet your therapist? * This field is required.Monday-Friday 9am-9pm Saturday 9am-5pm Please place a range of time. (MUST ANSWER)
10
Are you over the age of 14yrs?* This field is required.
YESNO
11
Name of parent/guardian (if under 14 years)Name of parent/guardian (if under 18 years)
12
Client First Name* This field is required.If you are the client, please place your name. If you are completing the form for the prospective client, please place their name.
13
Client Middle NameIf you are the client, please place your name. If you are completing the form for the prospective client, please place their name.
14
Client Last Name* This field is required.If you are the client, please place your name. If you are completing the form for the prospective client, please place their name.
15
What type of therapy services are you looking for?* This field is required.
Individual
Family
Couples
16
List the other participant's Full Name, Phone Number, and Email* This field is required.Couples and Family Therapy Services
17
Your Birth Date* This field is required.
Date
Month
Day
Year
18
Your Age* This field is required.
19
Your Race/Ethnicity* This field is required.
20
Your Gender* This field is required.
Male
Female
Other
21
Full Address* This field is required.
Address
Address line 2
City/Town
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip/Post Code
Please Select
Please Select
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
22
Phone Number* This field is required.Best number to contact you
Area Code
Phone Number
23
May we leave a message* This field is required.
YESNO
24
Do you have any legal involvement?* This field is required.
Yes, I have legal Involvement.
No, I do not have any legal involvement
Other
25
Is therapy court ordered for the following reasons: Restraining Order, Custody Case, Supervised Visitation, Alcohol-related.* This field is required.
Yes, I have legal involvement and court-ordered therapy for one of the reasons listed above.
No, I do not have legal involvement and court-ordered therapy for one of the reasons listed above.
26
Do you have a preferred therapist?* This field is required.
Yes
No
27
What is your Preferred Therapist?ex. male, female, black etc.
28
Do you need medication management? * This field is required.We ONLY provide you with therapy services, but do not provide medication management
YESNO
29
Do you need medication management?
Yes
No
30
Do you have an untreated addiction? * This field is required.
YESNO
31
Are you currently getting treatment for substance use?* This field is required.
Yes, I am in an inpatient program
Yes, I am in an intensive outpatient program
Yes, I have recently been discharged from an inpatient or intensive outpatient program.
No, I have never been in an inpatient or intensive outpatient program.
32
If yes, please specify which substance:* This field is required.
33
Self-harm is defined as deliberate injury to self that necessitates medical care in the home or medical setting. Have you engaged in self-harm in the past six months?* This field is required.
YESNO
34
Have you ever experienced suicidal thoughts/ideation?* This field is required.
Yes, I have experienced suicidal thoughts/ideation in the past year
Yes, I have experienced suicidal thoughts/ideation over a year ago
No, I have not experienced suicidal thoughts/ideation in the past six months
35
Have you ever made a plan or an attempt to kill yourself?* This field is required.
Never
Yes, in the past six months
Yes in the past 2 to 5 year
Yes, it has been over 5 years
36
Have you been hospitalized for a suicide attempt in the past year?* This field is required.
YESNO
37
Do you hear voices or see things that others don't see or take medication for this?* This field is required.
YESNO
38
Marital Status
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
39
For couples or family therapy only, please list Partner Name/Age(If this applies to you)
40
For family therapy only, please list any children/age:
41
Cell/Other Phone
Country Code
Area Code
Phone Number
42
E-mail:* This field is required.
43
May we email you?* This field is required.*Please note: Email correspondence is not considered a confidential medium of communication.
YESNO
44
How did you hear about us?
Should be Empty: