New Client Interest Form

If you are seeking counseling please complete the New Client Interest form below. Be sure to complete each question, as applicable, and be sure to let us know your reason for seeking counsel and your availability. Once you’ve completed the questionnaire click the submit button. When your interest form is received one of our office staff will contact you as soon as possible. If you are willing to meet with an Associate Marriage & Family therapist (AMFT) or a Trainee at a sliding fee please answer Yes to that question.

Today's Date

YYYY

Referred by

(i.e.: Doctor; Insurance; Friend; etc)

Reason for seeking Counseling and/or Comments

Client Name

Client Date of Birth

Client Availability

Please list days and times that work best for you; we will do our best to accommodate those days and times

Name (Parent/Legal Guardian if client is a minor)

Contact Phone Number

(###)

###

####

Mailing Address

Primary Insurance

(If you have more than 1 Insurance Carrier please disclose both Primary and Secondary Insurance)

Insurance ID Number

Insurance Group Number

Insureds' Name

First Name

Last Name

Insureds' Date of Birth

Insureds' Employer

(If Insurance is through an Employer list Employer name. If not applicable put NA)

Insurance Phone Number

(This number is typically found on the back of your Insurance ID Card and will be listed as Provider Services)

(###)

###

####

2nd Insurance? If Yes please list that information below. If No put N/A below.

EAP Authorization Number

(If you have an Employee Assistance Program and have obtained an Authorization please list that number below. If not applicable put NA)

Therapist Preference

If we are unable to schedule you with a Provider covered by your Insurance are you willing to meet with an AMFT (Associate) or a Trainee at a sliding fee? This could also help you get scheduled sooner. Answer YES or NO below.