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. Your application will not be accepted.

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.

8

Select Location* This field is required.

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

Age of Client:* This field is required.

13

Declaration of CustodyPlease choose one of the following three options regarding your custody arrangement for the above-named patient:

I have full legal custody of this patient. I have complete authority to make decisions regarding my child's mental health needs

There is no legal declaration of custody for this patient. I have complete authority to make decisions regarding my child's mental health needs

I share legal custody for this child. I understand that BBC must contact the patient's other legal guardian before providing treatment, and I agree to this contact.

14

Name of legal guardian

First Name

Last Name

15

Phone number of other legal guardian

Please enter a valid phone number.

16

Email address of other legal guardian:

example@example.com

17

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.

18

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.

19

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.

20

What type of therapy services are you looking for?* This field is required.

Individual

Family

Couples

21

List the other participant's Full Name, Phone Number, and Email* This field is required.Couples and Family Therapy Services

22

Client Birth Date* This field is required.

Date

23

Client Race/Ethnicity* This field is required.

24

Client Gender* This field is required.

Male

Female

Other

25

Full Address* This field is required.If you do not live in PA, your application will not be accepted.

Address

Address line 2

City/Town

State

Zip/Post Code

Country

26

Phone Number* This field is required.Best number to contact you

Area Code

Phone Number

27

May we leave a message* This field is required.

YESNO

28

Were you referred by anyone?* This field is required.

29

Do you have any legal involvement?* This field is required.

Yes, I have legal Involvement.

No, I do not have any legal involvement

Other

30

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.

31

Does you have a preferred therapist?* This field is required.

Yes

No

32

What is your Preferred Therapist?* This field is required.ex. male, female, black etc.

33

Do you need medication management? * This field is required.We ONLY provide you with therapy services, but do not provide medication management

YESNO

34

Do you need medication management?

Yes

No

35

Do you have an untreated addiction? * This field is required.

YESNO

36

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.

37

If yes, please specify which substance:* This field is required.

38

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

39

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

40

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

41

Have you been hospitalized for a suicide attempt in the past year?* This field is required.

YESNO

42

Do you hear voices or see things that others don't see or take medication for this?* This field is required.

YESNO

44

For couples or family therapy only, please list Partner Name/Age(If this applies to you)

45

For family therapy only, please list any children/age:

46

Cell/Other Phone

Country Code

Area Code

Phone Number

47

E-mail:* This field is required.

48

May we email you?* This field is required.*Please note: Email correspondence is not considered a confidential medium of communication.

YESNO

49

How did you hear about us?