New Client Scheduling Form

New Client Scheduling Form

Thank you for trusting us with your mental healthcare - we’re honored to support you. This form helps us understand your needs so we can thoughtfully match you with the right clinician and get you scheduled as efficiently as possible. All information you share is securely collected through an encrypted, HIPAA-compliant platform and is used only for matching and scheduling purposes. We take your privacy seriously and have safeguards in place to protect your information at every step. If you have any questions as you go, please reach out to us by emailing contact@chosenpathcollective.com.
IMPORTANT NOTE BEFORE YOU BEGIN:

For security reasons, this form will time out after a period of inactivity, and unsaved information cannot be recovered.

Please plan to complete this form within the same calendar day that you start it.

This form includes 7 pages of questions and should take about 20-30 minutes to complete.

This form works best on a computer, laptop, or tablet. Mobile phones may not display all features correctly.
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):

Other
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) 000-0000Format: (000) 000-0000.
Pronouns:
Email Address:
example@example.com
Administrative Sex / Sex Assigned at Birth
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

Relationship or Family Counseling

If you aren't seeking Relationship or Family Counseling, you will be able to skip to the next page.
Are you seeking Relationship Counseling and/or Family Counseling?
Relationship Counseling and Insurance Disclaimer:
- If you're seeking Relationship Counseling, please note that Relationship Counseling at Chosen Path Collective is Self-Pay Only.
- For more information about why, please visit our website at https://chosenpathcollective.com/relationship-therapy/
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.Format: (000) 000-0000.
Partner / Family Member #1 Email Address:
example@example.com
Partner / Family Member #1 Date of Birth:

MonthDayYear
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.Format: (000) 000-0000.
Partner / Family Member #2 Email Address:
example@example.com
Partner #2 Date of Birth:

MonthDayYear
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.
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?
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:
Policyholder's Relationship to You:
Policyholder's Address (if different than yours):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload images in JPG, PNG, or PDF format. Maximum file size allowed is 5MB.
Upload Photo of Insurance Card (Front) *Please upload images in JPG, PNG, or PDF format. Maximum file size allowed is 5MB.*
Upload Photo of Insurance Card (Back) *Please upload images in JPG, PNG, or PDF format. Maximum file size allowed is 5MB.*

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.)
Main 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.)

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.
Terms and Conditions
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.
Submission Date

MonthDayYear
Should be Empty:

New Client Scheduling Form

Relationship or Family Counseling

Relationship Counseling and Insurance Disclaimer:

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