New Client Scheduling Form

Chosen Path Collective: New Client Scheduling Form

Thank you for trusting us with your mental healthcare. We’re honored to support you. This form is a key part of our matching and scheduling process. We know it’s a bit more in-depth than what you might find at other practices, but it’s designed that way for a reason: the more we know up front, the more thoughtfully we can match you with the right clinician and streamline the process of getting you scheduled for therapy. By completing this form, you're helping us avoid unnecessary back-and-forth and getting some of the more tedious logistics out of the way early so that we can focus on getting you the support you're seeking and not get hung up on paperwork. If you have any questions as you go, feel free to reach out: contact@chosenpathcollective.com
Who are you seeking services for?*
If seeking services for a minor, please enter their information below
If seeking services for someone other than yourself, please share your name, email address, and relationship to the client.
Name of parent / guardian / caretaker (skip this question if you're seeking services for yourself):

First NameLast Name
Relationship to client (skip this question if you're seeking services for yourself):

ParentLegal GuardianCaretakerOther
Contact Email (skip this question if you're seeking services for yourself):
example@example.com
What type of support are you seeking?*
Full Legal Name (required for insurance billing):*

First NameLast Name
Preferred Name (we'll exclusively use this name when addressing you):
Date of Birth*

MonthDayYear
Phone Number:*
(000) 000-0000
Pronouns:*
Email Address:*
example@example.com
Administrative Sex / Sex Assigned at Birth*

FemaleMaleI'm not using insurance and choose not to disclose.
We understand this question may not align with your gender, pronouns, or gender identity and we apologize for any discomfort in asking. We only need to know the anwser that's associated with your legal information for insurance billing purposes. If we submit claims to your insurance with the incorrect sex listed, this may cause you to owe a balance/claims to be denied. If you are not using insurance, you are not obligated to disclose.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please complete this page if you're seeking Relationship or Family Counseling

If you aren't seeking Relationship or Family Counseling, skip to the next page.
Partner / Family Member #1 Legal Name:

First NameLast Name
Partner / Family Member #1 Preferred Name (if different from legal name):
Pronouns:
Partner / Family Member #1 Phone Number:
Please enter a valid phone number.
Partner / Family Member #1 Email Address:
example@example.com
Partner / Family Member #1 Date of Birth:

MonthDayYear
Date
Partner / Family Member #1 Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner / Family Member #2 Legal Name:

First NameLast Name
Partner / Family Member #2 Preferred Name (if different from legal name):
Pronouns:
Partner / Family Member #2 Phone Number:
Please enter a valid phone number.
Partner / Family Member #2 Email Address:
example@example.com
Partner #2 Date of Birth:

MonthDayYear
Date
Partner / Family Member #2 Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If there are additional partners, please let us know when we send our email response to discuss scheduling.

Insurance Information

Please note we CANNOT accept Medicaid or Medicare plans at this time. This includes (but is not limited to): UPMC for You, Highmark Wholecare, Aetna Better Health, Gateway, GHP Family, and CCBHO.
If you're seeking Relationship Counseling, please skip this page. Relationship Counseling at Chosen Path Collective is Self-Pay Only. For more information about why, please visit our website at www.chosenpathcollective.com/services
Insurance /Payee Type:*
If you chose 'other' - please enter the name of your insurance carrier:
A Note About Self Pay & Privacy When Using Insurance:

Self-Pay is always the most private option available that allows you to have complete privacy and freedom in your treatment. This means that diagnoses are not required for you to receive the care you need.

* We are not in-network with Medicare / Medicaid insurance. Unfortunately, Self-Pay is not an option for recipients of Medical Assistance / Medicaid.
We recognize the difficulty for our clients who continue to encounter systemic barriers. Medicaid prevents recipients from paying out of pocket for any covered services [such as mental & behavioral healthcare].
Member ID # (please include any letters in your ID # / Enter N/A if not using insurance)*
Group # (if applicable):
Are you the primary policyholder?

YesNo
If you answered 'No' to the above question, what is the full legal name of the policyholder? (We will NOT contact this person, we just need to add their information to your account for billing purposes):

First NameLast Name
Policyholder's date of birth:

MonthDayYear
Policyholder's Administrative Sex:

FemaleMale
Policyholder's Relationship to You:
Policyholder's Address (if different than yours):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload Photo of Insurance Card (Front)
Upload Photo of Insurance Card (Back)

Presenting Concerns:

To help us find the right clinician for you, we'll need to know your reasons for seeking therapy. We request that you focus on your top 4 presenting concerns so that we're able to find the best clinical match. (If you have fewer than 4, that's ok, too. You're only required to pick one.)
#1 Presenting Concern:*
#2 Presenting Concern:
#3 Presenting Concern:
#4 Presenting Concern:
Anything else you'd like us to know to help match you with the right therapist? (You're welcome to share goals, preferences, identities, or past experiences that feel important.)

How did you hear about us? We're new and we'd really like to be able to thank anyone who's sending referrals our way.
We’re big fans of feedback. If there’s anything confusing, missing, or just annoying about this form, please let us know. Making this process better for our clients is important to us.
Terms & Conditions
Consent to Contact & Screen

I consent to be contacted by Chosen Path Collective (CPC) regarding scheduling and care coordination. I understand this screening form does not establish a therapist-client relationship.

Confidentiality & Crisis Disclaimer

I understand that the information I provide will be treated with care, but CPC is not a crisis response service. If I am in crisis, I will contact 911 or a local crisis line.

Clinician Matching & Insurance

I understand that CPC will use this information to match me with a clinician and create a client portal for me in their EHR system as a part of the scheduling process. Providing insurance info does not guarantee coverage, and I am responsible for verifying and understanding my insurance benefits before beginning treatment.
Submission Date*

MonthDayYear
Should be Empty:

Chosen Path Collective: New Client Scheduling Form

Please complete this page if you're seeking Relationship or Family Counseling

Insurance Information

Your Availability & Clinician Preferences

A Note About Availability & Scheduling

Presenting Concerns:

Terms & Conditions

Consent to Contact & Screen

Confidentiality & Crisis Disclaimer

Clinician Matching & Insurance