Intake Form

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Timber Creek Counseling Intake Form

Timber Creek Counseling Intake Form

Hello, please fill out and submit this form to be added to our intake list. This form takes approximately 1-2 minutes to complete. Do not use this form in case of emergency or if you or your child are feeling suicidal. Instead, please call 911, go to your nearest emergency room, or contact the national suicide hotline at 800-273-TALK (8255).

1
Who is this appointment request for?* This field is required.You can request this appointment for yourself, on behalf of someone else, or for both you and your partner. Please choose below.
Me
My Partner and Me
Someone Else
2
Your Name* This field is required.
First Name
Last Name
3
Your Email* This field is required.
example@example.com
4
Your Phone Number* This field is required.
Please enter a valid phone number.
5
Date of Birth* This field is required.
Date
Year
Month
Day
6
Insurance* This field is required.
Blue Cross Blue Shield (BCBS)
Blue Care Network (BCN)
Aetna
Physicians Health Plan (PHP)
HAP
Medicare
Out of Pocket
7
Partner's Name* This field is required.
First Name
Last Name
8
Partner's Email* This field is required.
example@example.com
9
Partner's Phone Number* This field is required.
Please enter a valid phone number.
10
Partner's Date of Birth* This field is required.
Date
Year
Month
Day
11
Is the potential client a minor?* This field is required.
Yes
No
12
Potential Client's Name* This field is required.
First Name
Last Name
13
Potential Client's Email
example@example.com
14
Potential Client's Phone Number
Please enter a valid phone number.
15
Potential Client's Date of Birth* This field is required.
Date
Year
Month
Day
16
What services is the potential client interested in?* This field is required.
Individual Counseling
Couples Counseling
Child/Adolescent Counseling
Psychological Assessment/Testing
Life Coaching
Group Counseling
17
What are the main concerns?* This field is required.Please select all applicable concerns.
ADHD
Adoption
Anxiety
Asperger's Syndrome
Assessment/Psychological Testing
Behavioral Issues
Depression
Divorce
Family Conflict
Grief
Impulse Control Issues
LGBTQ+ Issues
Marriage Issues
Men's Issues
Mood Disorders
Obsessive-Compulsive (OCD)
Parenting
Peer Relationships
PMDD
Pregnancy, Prenatal, Postpartum
Relationship Issues
School Issues
Self-Esteem
Spirituality
Stress
Trauma
Women's Issues
Other
18
Is the potential client open to online counseling?* This field is required.
YESNO
19
What is the potential client's schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.
I am flexible, first available.
Monday Morning (9am-12pm)
Monday Afternoon (12pm-3pm)
Monday Evening (3pm-7pm)
Tuesday Morning (9am-12pm)
Tuesday Afternoon (12pm-3pm)
Tuesday Evening (3pm-7pm)
Wednesday Morning (9am-12pm)
Wednesday Afternoon(12pm-3pm)
Wednesday Evening (3pm-7pm)
Thursday Morning (9am-12pm)
Thursday Afternoon (12pm-3pm)
Thursday Evening (3pm-7pm)
Friday Morning (9am-12pm)
Friday Afternoon (12pm-3pm)
Friday Evening (3pm-7pm)
Saturday Morning (9am-12pm)
Saturday Afternoon (12pm-3pm)
20
What are the goals/concerns to work on in counseling?* This field is required.Please also note here if you have a strong preference for a specific counselor and would like to be considered only for their waitlist. This could effect wait time.
Huge
Large
Normal
Small
Ok
Ok
21
How did you hear about us?
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