• Personal Information

    Group Therapy Request / Intake Form
    Personal Information
  • Client Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Are You Completing This Form On Behalf Of Someone Else?*
    • Additional Contact 

    • Your Information

      Please enter your information here if you are completing this form on behalf of someone else
    • Format: (000) 000-0000.
    • Is the Client Actively Seeking Counseling?*
    • End 
    • Where Did You Hear About Us?

  • Insurance Information

    Tompkins Community Counseling is in-network with Aetna
    Insurance Information
  • Format: (000) 000-0000.
  • Subscriber Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Attendance & Availability

  • đź“Ť Important Note:

    đź“Ť Important Note:

    All group therapy sessions are held strictly in person at our main office located in Ithaca.
  • Please indicate your general availability to attend weekly, in-person group sessions below. Check all blocks that apply to your schedule.
    Rows

  • Areas of Focus & Group Goals

    Areas of Focus & Group Goals
  • Please select which issue(s) you are looking to address with counseling:*

  • Preparing for Clinical Questions


  • A Brief Note on the Following Section

    Group therapy provides a highly effective environment for personal growth and mutual support. To ensure a cohesive experience for all participants, we must carefully evaluate the clinical alignment of each group.


    The following questions inquire about your current emotional well-being and any specific challenges you are navigating. We collect this sensitive information with the utmost care in order to:


    • Ensure an Optimal Match: Align your unique personal goals with the most appropriate group curriculum and peer dynamic.


    • Maintain Clinical Safety: Cultivate and preserve a secure, predictable, and therapeutic environment for all group participants.


    • Determine Appropriate Care: Verify whether group therapy is the safest primary treatment modality for your current needs, or if alternative care structures would better serve you.


    Please be assured that all responses are strictly confidential under healthcare privacy standards and are evaluated exclusively by our clinical intake team at Tompkins Community Counseling.


    Thank you for your transparency and collaboration in this process. Please click "Next" to proceed.

  • 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?*
    • Additional Information 
    • End 

  • Mental Health Treatment

  • Within the last year, have you been hospitalized for mental health treatment?*
    • Additional Information 
    • End 

  • Are you currently experiencing any of the following?

    (Check all that apply)
  • Type a question
    • Additional Information 

    • If you are currently experiencing suicidal ideations and are unable to keep yourself safe, please call 911

    • Have you previously attempted suicide?
    • End 

  • Schedule Your Phone Intake Appointment

  • During your phone intake appointment, we will:

    • Call your phone number at your scheduled appointment time
    • Answer any questions you may have
    • Work with you to finish setting up your client portal
    • Schedule your first appointment with the group

    If you are unable to keep your scheduled appointment time, you can use the link in your confirmation email to change your appointment.

    Or you can reach out to our Clinical Support Specialist, Melissa (607) 882-0686

  • Appointment*
  • Format: (000) 000-0000.
  • Should be Empty: