Therapy Screening & Scheduling Form
Complete this form to make an appointment for your free phone consultation.
Hello there!
Golden Crest Counseling, LLC has in-person spots available for those seeking a therapist for their child(ren) within the Frederick, Maryland area. We also have virtual openings for those located in Maryland, who are seeking telehealth therapy for their child(ren). *If you are interested in pursuing therapy for more than one child within your household, please be sure to submit a separate form for each child.
Important: Please read before completing this form.
Please note that these forms are not monitored daily and never reviewed outside of business hours. We may not see notes about safety concerns immediately. Please call 911 or proceed to the nearest emergency room if you or someone you are supporting is at risk of harm, or in case of another emergency. Additionally, it is important to know that per Maryland state law, mental health professionals are mandated reporters. This means that we are required by law to make a report to the appropriate entity in the event that we know or suspect a child is experiencing abuse or neglect. If you include information on this form that leads us to have concerns for child abuse or neglect, we will report as mandated.
Contact Information & Scheduling Services
Let us know how to get in touch, and schedule your free phone consultation today!
Name of Person Completing Form (Parent/Guardian's Name)
*
First Name
Last Name
Pronouns
Phone Number *This is the number we will call during your free phone consultation.
*
Please enter a valid phone number.
Email *This is the email we will send reminders and any follow-up information to.
*
example@example.com
Appointment for Free Phone Consultation
*
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Client Information
Please check to ensure that all information is correct before continuing on to the next page.
Name of Client (Child's Name)
*
First Name
Last Name
Client's Legal Name (if different) *This is the name that must be listed on superbills for insurance reimbursement.
First Name
Last Name
Pronouns
Client's Age
*
Client Address *This location must be within Maryland, as our clinicians are only able to provide in-person and virtual therapy services to clients who are currently located within their state of licensure.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Therapy Screening
Please indicate your reason(s) for exploring therapy as a helpful option for your child.
Which type(s) of therapy are you interested in for your child?
*
In-person individual therapy (Office in Frederick, Maryland)
Online individual therapy (Available only in Maryland)
Has your child ever been to therapy before?
*
Yes
No
What are your reason(s) for seeking support for your child? Check all that apply. My child...
*
Has unrealistic thoughts, worries, or fears
Has sleeping problems
Complains of frequent headaches, stomachaches, or other physical symptoms
Has trouble separating from me
Has anxiety or panic attacks
Has repetitive, rigid, or strange behaviors
Can be overly self-critical or perfectionistic
Avoids specific places, activities, or things
Seems very angry or irritable
Has trouble paying attention or focusing
Is fidgety, impulsive, or hyperactive
Is having problems in school
Struggles to make friends or interact with peers appropriately
Seems very emotional, moody or sad
Has expressed thoughts of self-harm or suicide
Has engaged in self-harming behavior(s) or attempted suicide
Often breaks rules or gets in trouble
Does things that are risky or dangerous
May be abusing alcohol, tobacco, or other drugs
Has eating or body image issues
Is exploring their identity
Do you have any other concerns for your child that were not listed above?
*
Yes (We can discuss these other concerns during the phone consultation.)
No
How did you hear about us?
*
Facebook Business Page for Golden Crest Counseling, LLC
Instagram Account for Golden Crest Counseling, LLC
Psychology Today Profile
Business Website for Golden Crest Counseling, LLC
Recommended by a Mental Health Professional
Recommended by a Friend or Family Member
Other
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