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New Client Intake Form
Prior to beginning therapy services, please complete the following form in its entirety and click 'submit'.
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* Indicates required question
Client's Name (s) (Last name, First name):
*
Your answer
Client's Date of Birth:
*
MM
/
DD
/
YYYY
Client's Home Address (City, State, Zip Code):
*
Your answer
Client's Contact Number (or guardian's number if client is under 18):
*
Your answer
Client's Email Address (
or guardian's email if client is under 18):
*
Your answer
What is your preferred method of contact (for your therapist to contact you regarding services)?
*
Email
Phone
Text
What form of counseling are you seeking?
*
Individual
Couples
Family
How will you be covering payment for services?
*
Self-pay
Insurance
Scholarship or voucher
If you are using insurance, please provide your Member Id & Group Number along with your carrier (e.g. M: YOP543685, G:71453, BCBS PPO).
Your answer
What would you like to address in therapy?
*
Your answer
When are you available for therapy (virtually)?
Note: You must be an Illinois resident.
*
Mon Afternoons (12-5 p.m.)
Mon Evenings (5-10 p.m.)
Tues Afternoons (12-5 p.m.)
Tues Evenings (5-10 p.m.)
Thurs Afternoons (12-5 p.m.)
Thurs Evenings (5-10 p.m.)
Fri Afternoons (12-3 p.m.)
Required
How did you hear about
The Heart Speaks?
*
Current/Former client
Friend/Colleague
Referral
Google search
Directory (e.g. Therapy for Black Girls, Psychology Today, etc)
Other
Are you interested in joining any support groups?
Yes
No
Clear selection
If yes, what type of group are you interested in joining?
Your answer
Submit
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