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Prospective Client Form
Please complete this form honestly and in its entirety. Once we receive your information, we will be in touch within 7-10 business days with information about next steps.
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IMPORTANT - This form is to be used for scheduling and administrative purposes. Please note there is no guarantee that responses will be received in a timely manner.
If you are in crisis, please call 911, 988 (National Suicide Prevention Lifeline - call or text), or the Center for Community Resources (1-800-643-5432, available 24/7) or visit their office at 2100 E. College Ave., Ste A, State College PA 16801.
By checking the box below, I indicate that I will contact the crisis resources above in the event of a physical or mental health emergency.
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I understand
Client First Name
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Your answer
Client Last Name
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Your answer
Client Age
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Your answer
What is your relationship to the client? (ex: self, parent, spouse, etc.)
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Your answer
Name of person completing the form (if different from client)
Your answer
Phone number
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Your answer
Is it okay to leave a voicemail?
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Yes
No
Email Address
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Your answer
Preference for contact
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Phone
Email
No Preference
What insurance carrier(s) do you have? If you do not have insurance or prefer nor to use insurance to cover sessions, please select private pay.
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Highmark Blue Cross Blue Shield
Capital Blue Cross
Other Blue Cross/Blue Shield Plan
Aetna
Geisinger (Commercial plans - NOT Geisinger Family Plan)
United Healthcare/Optum
United Healthcare Student Resources
Medical Assistance (Community Care Behavioral Health, UPMC for You, Amerihealth Caritas, Geisinger Family Plan, etc)
CHIP
Medicare
Cigna
Tricare
Private Pay
Other:
Required
Do you have flexible availability for sessions during business hours (9am-4pm M-F)? If not, please describe your availability.
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Yes
No
Other:
Do you have a preference for in person or virtual sessions? We can only offer virtual sessions to clients who are located in Pennsylvania at the time of service.
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In person (State College)
Virtual
No Preference
Do you live in Pennsylvania year round, or are there seasons of the year (ex: college breaks) when you will be out of state for an extended period of time?
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I will be in PA year round
My permanent residence is in a different state
Other:
Do you have any preferences about your therapist? These could include a preference for a specific therapist, gender preference, religious preference, or a specialist in a particular area. If you have no preferences, leave this field blank.
Your answer
Which are you interested in?
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Individual Therapy
Couples Therapy
Family Therapy (family therapy is only offered virtually at this time)
Intensive Therapy
Psychological Assessment/Evaluation (ages 0-18 only)
Other:
Required
Reasons for treatment (select all that apply):
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Anxiety
Stress
Depression
Trauma
OCD
ADHD
Disordered Eating
Relationship Challenges
Autism
Emotion regulation/anger management
Life transitions
Sexual/gender identity exploration
Substance Use
Self-harm
Suicidal Ideation
Other:
Required
Brief history of presenting concerns (optional)
Your answer
How did you hear about us? (ex: website, Psychology Today, friend/family member, etc.)
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Your answer
Thank you for taking the time to complete this form! Please allow 7-10 business days for someone to be in touch.
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