The Jump Start-Mental Health Therapy Registration

The Jump Start-Mental Health Therapy Registration

Please take a few moments to fill out this form carefully. Once you have been selected, you will be notified via the *email address and/or phone number provided. If not immediately selected, you'll be notified that you've been added to our waiting list and be alerted via email or phone call once your session has been approved.
PLEASE NOTE THAT BY FILLING OUT THIS FORM, YOU ARE AUTHORIZING YOUR THERAPIST TO SUBMIT CLAIMS TO 57 NORTH HAMPTON ON YOUR BEHALF FOR BILLING PURPOSES. NO OTHER INFORMATION WILL BE SHARED WITH US WITHOUT YOUR CONSENT.

*If you haven't heard from us within a week, please check your spam folder.
Name*

First NameLast Name
Are you older than 16?*

YesNo
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate your race/ethnicity (select all that apply):*

Asian or Asian AmericanBlack or African AmericanHispanic or LatinxNative American or Alaskan NativeNative Hawaiian or Pacific IslanderWhite or CaucasianOther
Do you have health insurance or are you covered by an Employee Assistance Program?*

YesNo
If you selected "yes", does this cover mental health care?*

YesNoI do not have health insurance and am not covered by an Employee Assistance Program
If you do have insurance that covers mental health care, why have you chosen to apply to join The Jumpstart? (provide as much detail as possible) *
What's been the biggest obstacle you've faced in receiving mental health care?*
Are you:*

Looking for a solution to a specific problem?Looking for a long term therapist?Group therapy
Please describe your reasons for seeking treatment at this time. Include when the problem started.*
How long has this problem been present?*
How does this effect your daily life?*
Have you ever received mental health therapy?*

YesNo
If you selected "yes", what type of therapy did you receive?
If you have received therapy, what worked? What didn't work?*
Please indicate whether you are or have struggled with the following issues:

DepressionAnxietyStressGrief/LossLD/ADHDObsessions/CompulsionsTraumaChronic IllnessChronic PainLonelinessEating DisordersAbuseDomestic ViolenceManic EpisodesRelationship IssuesSexuality IssuesFamily ConflictBehavioral ProblemsSchizophrenia/PsychosisPhobiasDrug/Alcohol AbuseOther
OPTIONAL: Select a preferred therapist. (You can review their bios at www.57NHampton.com)

Brittany Scott-Positivity Amplified CounselingCheneka Moss-Huntsville Psychotherapy and Counseling ServicesJanene Yost-Growth Point CounselingJennique Robinson-Robinson Counseling and ConsultingLynn Rucker-Arise and Shine CounselingSandra Griffin-Changing Lanes Christian Wellness Ministries and Counseling CenterWISCONSIN ONLY Leah Bruce-Navigate Wellness Health Group
In the event that there is more than a two week wait for you to see your therapist, are you open to working with a Master's Level Intern while you wait?*

YesNo
How did you hear about us?
Would you like to be added to our email list?

YesNo
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