Counseling Screening Form

Counseling Screening

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

First NameLast Name
Preferred Name (if different from above)

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How Did You Hear About Us? (ex., friend, web search, doctor)*
What Type of Counseling are You Looking for?*
Client Age*

3-56-1213-1718-2425-3031-4041-5051-6061-7070+
Client Age*
Days Available for Scheduling (pick one or more)*

MondayTuesdayWednesdayThursdayFridaySaturdaySundayI'm flexible
Best Times for Scheduling (pick one or more)*

8-11am11am-2pm2pm-5pm5pm-9pmI'm flexible
Any Preferences for Your Therapist? (choose all that apply)*

MaleFemaleReligious basedNon-religious basedLGBTQIA+ trainedYounger than 40 years oldOlder than 40 years oldPerson of colorI'm flexible
How Do You Prefer to Meet for Therapy?*

In Person/At OfficeVia Phone/Telehealth
Do you have Medicaid or Medicare (including Ambetter, MO HealthNet, Healthy Blue, Golden Rule, etc.)?*

YesNoNot Sure
Are You Planning to Use Insurance?*

YesNoNot Sure
Which Insurance(s) are You Planning to Use? (Choose all that apply)*

AetnaAnthemBlue Cross/Shield (BCBS)CignaComPsychCoventryHealthLinkHumanaMagellanOptumUnited HealthcareWellcareOther
Please Describe*
What Amount Seems Affordable for You to Pay (per Counseling Session)?*

$0-$30$30-$50$50 or moreOther
Please Describe*
Please briefly describe why you are seeking counseling services*
How Do You Prefer to Be Contacted?*

EmailPhone CallText
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