Screening/Waitlist Form - Becca McConnell LPC-S

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please provide the following information, and be sure to add becca@beccamcconnell.com to your contacts list, as I'll be contacting you from this address. Once a space becomes available, ALL parties with email addresses listed below will be directly contacted with paperwork packets and instructions for scheduling appointments.

FAILURE TO COMPLETE ALL QUESTIONS FULLY WILL RESULT IN BEING SKIPPED OVER/NOT CONTACTED.

**In the event of a wait, it’s always your choice to discontinue your wait for services with me and proceed with another therapist if the immediacy of the situation calls for it.

Please note that I do not accept insurance and that all services are private pay. Couples therapy typically is NOT covered by insurance, regardless of working with an in- network provider or an out-of-network provider. Please check the box below indicating that you are aware of this before proceeding.

I understand I'll be paying privately for services. Couples therapy generally isn't reimbursable by insurance.

Full name(s) ***BOTH names needed for couples therapy: *

Best contact phone number(s) ***BOTH numbers needed for couples therapy: *

Best contact email address(es) ***BOTH emails needed for couples therapy: *

Type of Therapy Requested: *

Couples Therapy

Individual Therapy

Premarital Counseling

Are you a previous client or a new client? *

Previous Client

New Client

How did you hear about my services? *

Yelp

Word of Mouth

Google/Internet Search

Referral from doctor/another therapist

Other:

Besides "couples/individual counseling", can you tell me what types of problems you'd like to address in therapy? (Your answer helps me screen for issues I may not be the best fit for, and can let you know that quickly without you having to come into the office for an appointment.) *

Preference between in-office sessions vs. virtual sessions? *

FIRST AVAILABLE/shorter wait prioritized over virtual vs office meetings

Prefer in-office sessions, but am open to virtual appointments sometimes if needed

Only IN-OFFICE sessions preferred; not open to any virtual sessions at any time

Only VIRTUAL sessions preferred; not open to meeting in person at this time

Prefer virtual sessions, but am open to in person sometimes if needed

Are you currently involved in any kind of legal/judicial hearings (ex. custody battle, divorce proceedings, etc.) or expect to be in the near future? *

Yes

Not now, but it's a possibility this may change

Anything else you'd like me to know?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Becca McConnell LPC-S. Report Abuse

Forms