Request a New Client Phone Call

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Request a New Client Phone Call - Adult

WHO: If you are seeking services for YOURSELF, please complete this form. If you are parent who is interested in services for your child, please go back and select the "Child/Teen" form.

WHAT: This is a brief screener to help me understand if the services I offer might be a good fit for you. It should only take about 5 minutes to complete.

NOTE: Completing this form does NOT constitute a therapeutic relationship. This form is NOT monitored to report any concerns for safety or any psychiatric emergencies. I do NOT provide crisis management services. In the case of any mental health emergencies, call 911 or go directly to the nearest emergency room. *

I understand and agree.

HIPAA/ELECTRONIC SAFETY/SECURITY WARNING: I use HIPAA compliant products and employ HIPAA-compliant practices to safeguard the integrity and privacy of clients' personal information. That said, no software or electronic service can be guaranteed to be 100% secure and submission of this form is at the risk of the user. By submitting this form, you are accepting and agreeing to the inherent risks involved. *

I understand and agree.

What benefits would you be using?:

Lyra

Aetna

Meritain Health

Out of network (OON). I will pay upfront and request reimbursement from my insurance company myself.

My appointment times are Monday thru Thursday from 10 or 11am to 4pm (last appt at 3pm) and Fridays at 10am, 11am, 12pm only. I do not have evening or weekend appointments. Are there certain days or times within those slots that you would need?

Your First Name: *

Your Age: *

Your Email (I will use this address to follow up with you about scheduling): *

Your best call back phone number: *

How did you hear about my practice? *

Lyra

Aetna

Headway

Psychology Today

Internet search

Other:

Your Occupational (work) Status: *

In school.

Working part-time.

Working full-time.

Raising children or caring for family member(s).

Retired.

On disability.

Other or in transition.

Required

Have you worked with a counselor or therapist before? *

No.

Yes, about 1-5 visits.

Yes, about 6-12 visits.

Yes, more than 12 visits.

Required

Any current or recent concerns? *

Stress, worry, or anxiety.

Panic symptoms or panic attack(s).

Sleep problems.

Moodiness or irritability.

Feeling somewhat down, "blah," or "in a funk."

Feeling quite down, sad, or depression for a period.

More stressed or sad related to situational factors.

More stressed or sad UNRELATED to situational factors.

Grief related to a loss or death.

None of the above.

Other:

Required

Any CURRENT or RECENT concerns related to safety, health, or wellbeing? (Within the past 1 year.) *

Self-harm.

Thoughts of self-harm.

Trauma.

Abuse.

Substance use.

Eating disorder.

Restricted or disordered eating.

Aggression towards others or property.

Thought disorder or psychosis.

None of the above.

Other:

Required

Any PAST concerns related to safety, health, or wellbeing? *

Self-harm.

Thoughts of self-harm.

Trauma.

Abuse.

Substance use.

Eating disorder.

Restricted or disordered eating.

Aggression towards others or property.

Thought disorder or psychosis.

None of the above.

Other:

Required

Any current or past history of learning or developmental concerns?: *

Learning disability.

Hyperactivity.

Distractibility or poor attention.

Autism spectrum disorder.

None diagnosed but have questions/concerns.

None of the above. No questions/concerns for any of the above.

Other:

Required

Are the current issues related any of the following? *

Automobile accident/injury.

Medical malpractice.

On the job injury or worker's compensation.

Divorce or custody issue.

None of the above.

Required

Briefly, why are you thinking about starting counseling? What would you like to work on? *

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