JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Carla Barnes LPC, PLLC Counseling Services Request
Thank you for contacting us! We are honored at the possibility to provide counseling services to you and/or your family. Please complete this form to be put on the list. We will be in contact with you as soon as a slot opens up.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date
*
MM
/
DD
/
YYYY
Client Name
*
Your answer
Client Age
*
Your answer
Presenting Concern (what issue or situation is leading to stress, depressive, anxious, etc. feelings)
*
Your answer
Method of Payment (currently not taking Superior/Tricare)
*
Private Pay
BlueCross BlueShield
UnitedHealthCare
ComPysch
Optum
Oxford
Oscar
Aetna
UMR
Bind
ChampVA
GEHA
Other
Is there a clinician preference? Note: Each clinician has their own specialties and different insurances that they take. Click link to find out more about each therapist.
https://www.carlabarneslpc.com/meetthetherapists
*
No Preference, 1st available with best fit of client needs
John Oncken LCSW: Sees 8+ children, teens, adults, and couples
Casey Powers LMFT: Sees 10+, teens, adults, couples, and families
Ashley Davis LPC: Sees 12+ teens, adults
Karli Soule LPC: Sees 12+ teens, adults, couples, families, Virtual Only
Carla Barnes LPC: Sees Adults, Virtual Only
NPE/MPE Support-Surprise DNA Discoveries See website for more information
Katrina Cleveland LPC: Sees 13+ teens, adults, couples, and famileis
Other Important info regarding schedule and circumstances:
Your answer
Person Completing Form
*
Your answer
Contact Phone Number
*
Your answer
Contact Email
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Carla Barnes LPC, PLLC.
Report Abuse
Forms
