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Peace'In'It Counseling, LLC
Telehealth Counseling Referral Form
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Email
*
Your email
Legal First & Last Name
*
Your answer
Phone Number
*
Your answer
Art by
PixieCold
Telehealth Readiness Screening (Check All That Apply)
*
Are you a resident of Virginia?
Are you a resident of D.C.?
Are you comfortable with telehealth (2-way audio/video) services?
Are you 12 or older?
Do you have a reliable, stable internet connection?
Do you have a quiet, private, & well-lit setting to meet in consistently?
Have you previously participated in counseling?
Required
Anticipated Form of Payment
*
Self-Pay/Private Pay
Insurance - Anthem
Insurance - Blue Cross Blue Shield
Insurance - Cigna
Other:
What would you like counseling to help you with? (i.e. What brings you to services?)
*
Your answer
Referred By:
*
Current/Former Client
Friend of the Practice/Word of Mouth
Peace'In'It Counseling Website
PsychologyToday Profile
Social Media Handle
Other:
Required
Would you like to work with Petra(she/her) or Prell(he/him)?
*
Petra
Prell
No Preference/First Available
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