IAC Prospective Client Form

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Please complete this form as an initial step to establishing an initial consultation with IAC.

* If you are seeking immediate support for severe emotional distress, please contact 988 via text/phone for free confidential 24/7 emotional support & community resource assistance through the Suicide & Crisis Lifeline. For mental health emergencies please immediately contact 911 or go to your closes emergency room.*

Full Name: *

Pronouns:

He/Him

She/Her

They/Them

Prefer Not to Answer

Other:

Residential Location (City, State): *

E-mail: *

Phone Number: *

Referral Sources (How did you hear about IAC)?: *

Payor Source (ex: insurance (aetna), self pay, etc..): *

Are you an adult (20 yrs or older)? *

Yes

Are you seeking individual counseling? Please note IAC currently only provides individual services. *

Yes

What is your reason for seeking counseling at this time?: *

Submit

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