Gender-Affirming Care Referral Inquiry Form

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Must be completed prior to an initial consultation call being scheduled.

Legal name (first and last) *

Please tell me the name you'd like me to address you by, if different than your full legal name, and your pronouns, so that I may refer to you correctly. *

Age *

Phone number *

Email address *

Please provide me with your permission to contact you via your preferred method.

I give permission for Heather Stambaugh, LMHC LPC NCC to contact me via... *

Phone call

Text Message

Any of the above

Required

How did you hear about my referral services?

(i.e. Google search, specific therapist or health care provider referral, client referral, etc.) *

Have you ever been in therapy before? If yes, when and what were you being seen for?
*

I currently only accept Aetna and Cigna insurance. I do not accept any other plans.

You are responsible for contacting your insurance company and ensuring that I am in-network with your specific plan. If a claim is returned to me unpaid from insurance, you are responsible for that cost. Sometimes claims can remain unpaid for weeks so we may not become aware of denials until you have been seen several times, so it is advised to make sure before beginning services to avoid a large unexpected bill. I am not contracted with any Medicaid/Medicare plans at this time. Also, please be aware that when using insurance: 1) All insurance companies require therapists to provide accurate diagnoses in order to pay for services, which will go on your medical record. 2) Insurance companies have the right to request and review therapy records. 3) Insurance companies have the right to limit the duration and frequency of therapy sessions, so scheduling will be based on medical necessity for those who choose to use their insurance benefits to pay for therapy.

I have read and understand the above message.

Required

If you do not have insurance, or I do not accept your insurance, my assessment and referral fee is $85.

I am able to offer one free assessment and referral each month as part of my pledge through the Gender Affirming Letter Access Project (GALAP)

I have budgeted to afford the $85 assessment fee.

I need a free assessment. I understand that only one free assessment is offered each month, so I may have to wait for an opening.

I will be using my insurance (Aetna or Cigna) for my assessment.

Required

Missed appointments for assessments or "no shows" will require a deposit of $85 via credit or debit card to reschedule the appointment. If you miss the rescheduled appointment, you forfeit your $85 deposit and will not be offered another opportunity to reschedule. This is the policy even if you are using your insurance (because insurance does not pay for missed appointments).

Free assessments are offered one reschedule. If you miss your rescheduled appointment, you will not be offered a second reschedule. I will instead offer you a referral list of other GALAP providers. *

I have read and understand the above message.

Required

I offer assessments both in-person and via telehealth.

In-person sessions are only offered on Wednesdays and Fridays at this time.

Telehealth sessions are offered on Tuesdays and Thursdays, and can be sometimes be offered on Wednesdays or Fridays if my schedule allows.

Which format do you prefer?

In-person in Lakeland, Florida

Telehealth from anywhere in Florida or Colorado

Either in-person or telehealth

If you have selected your hormone or surgery provider, please share their name and contact information here.
*

Please check all boxes that apply to you presently OR in the past. If none apply, please select that box.

(These are not immediately disqualifying for hormones or surgery, but will need to be further discussed during our assessment)

Hospitalization for a mental health reason

Suicidal thoughts

Suicide attempt

Eating disorder

Substance abuse/addiction

Extreme paranoia and/or psychosis (not being in touch with reality)

Self-injury/self-harm

None of the above apply to me

Required

Do you have any questions for me that you want to note here? If you would prefer to ask during our consultation, you may do so and leave this question blank.

When are you available to meet for sessions? Check all times that apply:

*Please note that I have listed all my working hours to gain an understanding of how aligned our schedules are and this is not an accurate representation of open time slots*

9:30AM

11AM

2:30PM

4:00PM

5:00PM (ONLY available on Tues, Wed, Thurs)

Tuesday

Wednesday

Thursday

Friday

If you have a strong preference for a certain hour or time slot listed above, you may note here. Thank you for taking the time to fill this out so that I can better prepare for our discussion. I look forward to meeting with you!

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