Please fill out this questionnaire so we can assist you in booking your first appointment:
Name of Potential Client
*
First Name
Last Name
If Child - Name of Parent/Guardian
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Preferred Office Location:
Please Select
556 S. Pike W, Sumter, SC (In-Person)
Telehealth in South Carolina
Greenville, SC (In-person, telehealth)
Are you seeking therapy for yourself or someone else?
Myself
My Child
A Family Member
Both Myself and My Spouse/Partner
Other
Do you have a preferred therapist you’d like to see?
Lydia Khan, MSW, LISW-CP (Sumter)
Jamie Manko, LPC, ATR (Sumter)
Elizabeth VanDermark, MSW, LMSW (Sumter)
What type of service are you seeking?
Individual Counseling
Art Therapy
Play Therapy
Couples Counseling
Family Therapy
Supervised Therapeutic Visitation
Clinical Supervision
What are the primary concerns/Goals that motivated you to seek therapy? Check all that apply
Anxiety
Depression
Work/Career Goals or stressors
Health Concerns / Chronic Illness
Life Purpose
Gender / Sexuality
Grief / Life after loss
Child Behaviors
Anger Management
Chronic / Persistent Mental Illness
Parenting Concerns / Struggles
Court Ordered Counseling
Court Ordered Supervised Visitation
Marriage / Relationship Concerns
Childhood Sexual Abuse
Childhood Abuse
DSS Involved
Adoption Issues / Concerns
Divorce
Child Custody Issues
Aging / End of Life
Other
How do you intend to pay for sessions? (please note that not all of our therapists are credentialed with these insurance companies. Please confirm with your insurance company what services they will reimburse for and if the clinician is in network with them. We can not guarantee coverage even if in network as each insurance plan is unique). ***We are not in network with Select Health***
*
Self Pay w/ Super Bill (Full Fee)
Self Pay w/ Sliding Scale (*With Provisionally Licensed Therapists without a Super Bill)
BCBS/PAI/PPO/SC State Benefits
Blue Choice Medicaid
Molina
Medicare (no supplemental)
United Healthcare
SC Medicaid
Tricare (We are Contracted Out of Network)
Unknown / Unsure
Other
Date of Birth of Potential Client
*
-
Month
-
Day
Year
Date
Gender on record with insurance
*
Please upload your insurance card so we can verify your benefits:
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Preferred appointment time?
Mornings - between 8:00 am and 11:00 am
Afternoons - between 12:00 pm and 4:00 pm (after school availability is severely limited)
Evenings - between 5:00 pm and 7:00 pm
Weekends
How did you hear about us?
Please verify that you are human
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