Tompkins Community Counseling - Request for Services Form

Personal Information

Couples Counseling
Type
Partner 1
Legal Name*

First NameLast Name
Preferred Name
Gender Identity / Pronouns Used
Date of Birth*

MonthDayYear
Date
Sex Assigned At Birth*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Partner 2
Legal Name*

First NameLast Name
Preferred Name
Gender Identity / Pronouns Used
Date of Birth*

MonthDayYear
Date
Sex Assigned At Birth*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where Did You Hear About Us?

WebsiteTCC Pamphlet / Business CardFriend / ColleagueLinkedIn / FacebookGooglePsychology TodayOther

Insurance Information

Tompkins Community Counseling is in-network with Aetna
Primary Insured*
Subscriber Name*

First NameLast Name
Subscriber Email*
example@example.com
Subscriber Phone Number*
Format: (000) 000-0000.
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Relationship to Patient*
Subscriber Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Provider
Insurance Card

Please upload images of the front and back of insurance card, if available
Cancelof

Preferences
Platform

Tompkins Community Counseling offers both Telehealth and In-Person options.
Do you have a platform preference?*

No PreferenceTelehealth / VirtualIn-Person
Clinician

Tompkins Community Counseling understands the importance of a good fit. We will try our hardest to match you with the clinician of your choice. However, based on availability, there may be a waiting list for certain clinicians
Do you have a specific clinician that you would like to request?*

First Available ClinicianYes
Meet our Team

Court Involvement

Examples of involvement in a court case include, but are not limited to: Family court, divorce, workers' compensation, disability, criminal court, and drug court
Are you currently involved in an open court case or are you court mandated to receive mental health counseling?*

YesNo
- Please provide information on your current court involvement:

Mental Health Treatment
Within the last year, have you been hospitalized for mental health treatment?*

YesNo
- Please provide additional information on any hospitalizations within the last 12 months:

Suicidal Ideations
Have you been experiencing suicidal ideations?*

YesNo
- If you are currently experiencing suicidal ideations and are unable to keep yourself safe, please call 911
- Have you previously attempted suicide?
  
  YesNo
- Please provide additional information:

Personal Information