• 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:*

  • 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: