Therapy Services Questionnaire
Thank you so much for reaching out. We would love to schedule a 15-minute phone conversation to discuss your needs and ensure we are a good fit to support your needs. Please complete these questions and we will be in touch soon. We look forward to connecting with you.
Client Name
*
First Name
Last Name
Parent/Guardian Name if different
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health Insurance Provider: (TDAS does not guarantee we can bill your insurance)
*
Please Select
Aetna
Alliance
AmeriHealth
BlueCross and BlueShield
Cigna
Healthy Blue
WellCare
Self-Pay
Enter your Insurance Member ID; or Secondary Insurance
Primary Care Provider (Name and Phone Number)
*
Are there any custody arrangements or other legal concerns?
*
Yes
No
If you answered yes, please explain.
Has there been a case with Child Protective Services (CPS) or Adult Protective Services (APS) in the last 12 months?
*
Yes
No
If you answered yes, please explain.
Reason(S) for seeking therapy. Please check all that apply
ADHD
Anxiety
Autism Spectrum Disorder
Behavioral Issues
Coping Skills
Depression
Developmental Disorders
Divorce
Family Conflict
Grief
Impulse Control Disorders
Intellectual Disability
Peer Relationships
Post Traumatic Stress Disorder
Relationship Issues
Self-Esteem
Sleep or Insomnia
Suicidal Ideation
Substance Use
Trauma
Other reason for seeking therapy or anything else you would like to share.
*
Preferred Office Location (we will do our best to accommodate location preference but cannot guarantee.)
*
Raleigh
Durham
Either
Submit
Should be Empty: