Welcome to Blue Skies Counseling!
This questionnaire is to help us learn about your needs and schedule you with a therapist. Completion of this form will add you to the client list. Due to high demand, please anticipate a 7-21 day wait to be contacted.
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Email *
Full Legal Name (for Insurance) *
Preferred name, (if different from Legal Name)
Birthday *
MM
/
DD
/
YYYY
Mobile Phone Number (for texts) *
Preferred Pronouns *
Required
How do you identify? (mark all that apply) *
Required
Therapist Preferences (mark all that apply)
All our therapists hold Telehealth sessions as well as in-person. 
 *
Required
Location Preferences *
Required
Day Preferences (mark "Any Day" OR the days you are available) *
Required
Appointment Time Preferences (mark "Anytime" or only the times you are available) These are start times; sessions are 50 minutes.
 *
Required
Which insurance(s) will you be using? (mark all that apply) If your insurance is not on this list we currently don't accept it. *
Required
If you will be using Medicaid which plan do you have? 
*Keep in mind that Mental Health coverage can be different than Medical coverage (Community Care), and plan providers vary. We can verify coverage for you. We DO NOT accept Optum. Please choose the plan you have from the choices below:
We only accept the following; (subject to verification):
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Please enter your Insurance Member ID, or take a picture of the front and back of your insurance card and send via text to 801-413-3740.
 Please add any comments to help us schedule you with a therapist who can best help.
Thank you for completing this questionnaire!

The time it takes to see a therapist depends on which therapist you choose, if you’d like Telehealth or in-person, the day and time that works for you, the therapist’s availability, and your preferred frequency. We will reach out to schedule a free 15 minute online consultation when we have a recurring spot available that works for you!

Due to high demand, please anticipate a 7-21 day wait to be contacted. If you would like help deciding on a therapist, questioning where you are on the waitlist, or have other questions, please text 801-413-3740 to contact us or request a phone call. Due to the nature of our practice, we have chosen to communicate through text. We look forward to meeting with you! 

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