CompassCC - request for counseling
Thank you for your interest in services from Compass Community Counseling.  Completing this form helps us to best follow up with you, and begin the process of matching you with one of our counselors.  All of your responses will be kept confidential.  

Completing this form does not guarantee CompassCC will be able to provide counseling services to you.  This form is also not intended for crisis or emergency response.  If you are experiencing a mental health emergency, please call 988 or go to your nearest emergency room.

If you have any questions, please email us at info@compasscc.org or
call/text (314) 246-9277
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What type of counseling are you seeking? *
Patient First Name (person to be seen by the counselor) *
Patient Last Name (person to be seen by the counselor) *
If counseling for child/adolescent (under 18), please enter the patient's age.
Patient Email address (or parent/legal guardian email if patient under 18)
(by entering your address, you grant us permission to contact you to discuss counseling services.)  Please skip this question and enter your phone number if you'd prefer we not to contact you via email.
Patient Phone number (or parent/legal guardian phone if under 18) *
If you are registering on behalf of another individual, please enter your name, relationship to the patient, and preferred contact information in this box. (Leave blank if registering yourself.)
May we leave a voicemail and/or text message the above number? (leave blank if you would prefer we not leave a voicemail or text)
What is your preferred method of service? *
Patient Gender Identity
Please select your preferences for being matched with a counselor (please check all that apply).  Note: not all clinicians are able to bill insurance, and some are limited in which insurance they can bill.
(* = waitlist only or not accepting new clients at this time) *
Required
If registering for couple's/marriage counseling, please enter your partner/spouse's email address. 
(by entering your address, you grant us permission to contact you to discuss counseling services.)  
How do you plan to make payment for services? 
note: not all clinicians can bill insurance, and some are limited in which insurance they can bill.
(If using a 3rd party payer, like a church or EAP, please enter the organization name using the "Other" option)
 *
Required
What times are you available for meeting with a counselor? Please check all that apply. 
*Note: We currently have a waitlist for clients seeking evening appointments.  We do not currently have any therapists offering Sat. or Sun. appointments.

Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Morning (8am-12pm)
Afternoon (12pm-5pm)
Evenings (5pm-8pm)
Would you like us to include a scholarship application in your intake packet? *
We offer reduced fees for those in financial need.  Scholarships are awarded based upon annual household income, number of dependents, and availability of scholarship funds.
Please briefly describe what you would like to work on in counseling. *
How did you hear about CompassCC? *
Is there anything else you would like us to know about you or your request for counseling?
Would you like to be added to our newsletter/email list to receive announcements about new groups, services, and events? *
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