Client Interest form

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This form is for clients interested in getting started at Compass Tree Counseling. Please have your insurance card ready when you are filling this out as you will need information from it.

We have a weekly staff meeting every Wednesday, and it is at that time our providers assess all intakes that have come in since the previous Wednesday and look for who is the best fit for each individual client. We then let clients know by the following Friday. (If an Intake is sent in Wednesday afternoon- Friday it will not be added to the list till the following Monday to allow our providers more time to look at the previous week.)

First Name *

Middle Initial *

Last Name *

Birthdate *

YYYY

Biological Sex *

Female

Male

Gender identity

Woman

Man

Non-binary

Other or prefer not to say

Clear selection

Preferred Pronouns

Email *

Address *

Phone Number *

Guardian's name if client is under 18

Primary Insurance Provider *

Policy Number *

Group Number *

Secondary Insurance and policy number (Leave blank if it doesn't apply)

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