Work with Me

Work With Me Questionnaire

Complete and submit this form if you are interested in becoming a client of Josh Kellar
Client's First Name *
Client's Last Name *
Email Address *
Phone Number *
Partner's First Name (If Applicable)
Partner's Last Name (If Applicable)
Partner's Email Address (If Applicable)
Partner's Phone Number (If Applicable)
Brief description of reason for seeking therapy. *
What makes you ready for counseling right now? *
How did you hear about Josh Kellar Counseling, PLLC *
How did you decide to work with Josh Kellar? *
Health Insurance

As a service to you, your insurance coverage (deductible, copay, etc.) will be verified. It is possible that a portion of the cost of counseling with Josh Kellar might be reimbursed through the submission of a superbill. Josh is currently not accepting new clients that require in-network insurance billing. The cost of sessions will be discussed during the free intake consultation.
Who is your health insurance with? Please list the company. *
(PPO, HMO, None/Private Pay)
Insurance Company Phone Number
Find this on the backside of your insurance card.
Insurance Member ID
Insured Client's Date of Birth

Month Day Year
Date
Thank you for your interest in seeing Josh Kellar for counseling. Once you click submit you will be taken to a scheduling calendar to set up a FREE consultaion. The appointment will allow you to ask some additional questions and hear about the counseling programs Josh has to offer.

Submission of form does not constitute an agreement to establish care.

All your information will be kept confidential.
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Work With Me Questionnaire