Counseling Screening Form

Counseling Screening

Let us help match you with one of our providers by answering the following questions
Client Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
What Type of Counseling are You Looking for? *
Client Age *

3-5 6-12 13-17 18-40 41-60 60+
Days Available for Scheduling (pick one or more) *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday I'm flexible
Best Times for Scheduling (pick one or more) *

8-11am 11am-2pm 2pm-5pm 5pm-9pm I'm flexible
Any Preferences for Your Therapist? (choose all that apply) *

Male Female Religious based Non-religious based LQBTQIA+ trained Younger than 40 years old Older than 40 years old Person of color I'm flexible
How Do You Prefer to Meet for Therapy? *

In Person/At Office Via Phone/Telehealth
Are You Planning to Use Insurance? *

Yes No Not Sure
Which Insurance(s) are You Planning to Use? (Choose all that apply) *

Aetna Anthem Blue Cross/Shield (BCBS) Cigna ComPsych Coventry HealthLink Humana Magellan Optum United Healthcare Wellcare Other
Please Describe *
What Amount Seems Affordable for You to Pay (per Counseling Session)? *

$0-$25 $25-$50 $50 or more Other
Please Describe *
Please briefly describe why you are seeking counseling services *
Should be Empty: