TCF Updated Intake Form

1

Your Name* This field is required.

First Name

Last Name

2

Your Email* This field is required.

example@example.com

3

Your Phone Number* This field is required.

Please enter a valid phone number.

4

Date of Birth* This field is required.

Date

5

Insurance* This field is required.

Medicaid - Must be "Straight" Medicaid

Out of Pocket (sliding scale)

6

Considering your income and essential expenses, what feels like a manageable and fair amount for you to pay per session/service at this time?

7

Please briefly explain.

8

What services is the potential client interested in?Please fill out one intake for each type of counseling.

Individual Counseling

Family Counseling

9

Please provide the number of family members who will attend counseling.

10

Please provide the ages of each family member.You can separate each age with a comma or semi-colon.

12

Please rank the locations according to preference

13

What is the potential client's schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.

Wednesday Early Sessions (9am - 1pm)

Wednesday Later Sessions (1pm - 6pm)

Friday Early Sessions (9am - 1pm)

Friday Later Sessions (1pm - 5pm)

14

What are the goals/concerns to work on in counseling?* This field is required.Also please note if you have any specific limitations to your availability. This could affect wait time.

15

How did you hear about us?