New Client Interest Form

If you are seeking counseling please complete the New Client Interest form below. By filling out this form, you acknowledge you are giving Trinity Ministries permission to verify your insurance benefit and contact you via phone or email to discuss scheduling an appointment. 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.

Date

YYYY

Client Name (1)

If you are seeking "Conjoint" Counseling please list both Client Names below

First Name

Last Name

Client Name (2)

First Name

Last Name

Client Date of Birth (1)

YYYY

Client Date of Birth (2)

YYYY

Client availability

Primary Contact Number & Name

(###)

###

####

Secondary Contact Number & Name

(###)

###

####

Primary Contact Email

Secondary Contact Email

Mailing Address

City, State, Zip+4

Primary Insurance

Insurance ID Number

Insurance Group Number

Insured's Name

Insured's Date of Birth

YYYY

2nd Insurance (if applicable)

2nd Insurance ID Number

2nd Insurance Group Number

2nd Insured's Name

2nd Insured's Date of Birth

EAP Information

If you were given an EAP by your Employer please list that information as well as the phone number to contact the EAP Department

Associate / Trainee

Please check Yes if you are willing to meet with an Associate or Trainee; check No if you prefer to be on wait list for a Licensed Therapist

New Client Interest Form

Trinity Ministries

Locations: