New Client Intake Form Please complete this form to request a service consultation to determine eligibility for services only. Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Please let us know the best time to reach youMorning: 9-11amAfternoon: 12-4pmEvening: 5-9pmWho is this service for? *Business/OrganizationChildCoupleFamilyFriendPartnerOtherWhat has prompted you to seek services today?What are three (3) things that you would like to achieve in the next 60-90 days?How did you hear about us?WebsiteGoogleFacebookInstagramPsychology TodayTherapy for Black GirlsClinicians of ColorTherapy DenSondermind ReferralHeadway ReferralAlma ReferralOpen Path Collective ReferralPath ReferalCollege/University ListingsWhat services are you interested in learning more about? *Concierge TherapyIndividual Therapy (18-50)Teen Therapy (13-17)Couples TherapyFamily TherapyParent TherapyGroup TherapySpeech TherapyOccupational TherapyRecreational TherapyRespite CareLife CoachingTeen CoachingFamily CoachingStepfamily CoachingRelationship CoachingCareer CoachingBehavior CoachingFinancial CoachingHealth & Wellness CoachingChildcare AssistanceMental Health ConsultingBehavioral ConsultingBusiness ConsultingAcademic ConsultingClinical Supervision-LCSWClincal Supervision - LPC/LMFTClinical Supervision- BCBA-RBTPre/Marital CounselingSupport GroupMedication ManagementAnger/Stress ManagementPsych TestingMental Health Skill BuildingSocial SkillsParent CoachingAddiction Recovery SupportCase Management ServicesVocational Services (Re-entry) AdultVocational Services (Re-entry) JuvenileMentoring- CareerMentoring- YouthHow will this service be covered?Anthem Blue Cross and Blue SheildUnited Health CareOxfordOscar HealthAetnaCignaCareFirst of VirginiaSelf PaySubmit
