Sunflower Clinical Group Intake Screening
Thank you for your interest in Sunflower Clinical Group. It is our hope that we'll be a good fit to work together and help you to reach your goals. This confidential form will allow us to get the information we need to potentially get your connected to a provider at Sunflower.

After completing the information in this form, our team will reach out to you within approximately 5 business days, or as soon as possible if our team is on holiday. Sunflower will reach out to you via email with an estimation of costs (if you are using insurance) and either a connection to a therapist or the option to go onto our waiting list.

Please note that this form is not an emergency or on-call service. If you are feeling unsafe, unwell, or have immediate concerns about your mental health or that of someone close to you, please dial 911 or visit the nearest emergency room for immediate care.
Full Legal Name *
Preferred Name (if different than legal name)
Email Address *
(Please Note that Sunflower will contact you via the email address you provide)
Phone Number *
Do you plan to use your insurance benefits to pay for therapy? *
What is your current health insurance provider? *
Required
Date of Birth *
MM
/
DD
/
YYYY
If client is a minor, please enter legal guardian or parent's full name and email address.
Insurance Member ID *
Insurance Group ID *
Do you have a preference for a specific Sunflower therapist? If so, enter their name here.
Briefly explain in broad terms what is bringing you to therapy at this time.
When would you be available for a recurring therapy appointment?
Morning (8am-11am)
Midday (12pm-4pm)
Evening (5pm-9pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is there any other information about your availability that would be good for us know?
How did you hear about Sunflower Clinical Group?
Sunflower Clinical Group does not offer 24-hour support. *
Please indicate your understanding that you will receive a response to this form within 5 business days in most cases, and that this is not an emergency or on-call service. If you are feeling unsafe, unwell, or have immediate concerns about your mental health or that of someone close to you, please dial 911 or visit the nearest emergency room for immediate care. Please select"Yes" below to indicate your understanding of the nature of this contact form.
Required
I understand that once I complete this questionnaire, I will be contacted via email within 5 business days with a benefits estimation and either a connection to a therapist to begin working with, or the option to go on a waitlist. I consent to being contacted via email. *
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