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Sankofa Referral Questionnaire
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* Indicates required question
Name:
*
Your answer
Option 1
Clear selection
Phone number :
*
Your answer
Address:
*
Your answer
email address
(
Please verify your entry is accurate)
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Gender :
*
Your answer
Referred by?
*
Sonoma Black Therapy Fund
Imani Church
100 Black Men
Destiny Christian Fellowship
Friend
Primary Care Physician
My insurance
Other:
Do you have an account number, authorization number, or voucher number?
*
Yes
No
Other:
Do you have health insurance?
*
Yes
No
What health insurance type?
*
Alameda Alliance
San Joaquin Health Plan
Medi-care
Kaiser
Blue Cross
Blue Shield
United Healthcare
Sutter Health
N/A
Other:
What is your insurance member ID?
Your answer
If your insurance is not accepted, are you able to pay out pocket? Fees range from $185 & up per session.
*
Yes
No
Maybe
Do you have HSA or FSA to pay for therapy?
*
No
Yes
Other:
Are you seeking counseling for yourself or someone else?
*
Your answer
If seeking therapy for a minor do you have full legal custody?
Yes
No
Other:
Clear selection
Reason for seeking therapy services:
*
Your answer
Have you ever been in therapy before? If yes, when were you last seen and for how long were you seen?
*
Your answer
Are you currently having suicidal thoughts or self-harming thoughts
*
Yes
No
If you replied yes to the above questions, please answer the following question.
If you answered no please go to the next question.
I am having current thoughts of suicide with a plan and intent to follow through
I have current thoughts of suicide with no plan or intent to follow through
Are you currently having any thoughts of harming others?
*
No
Yes
Other:
If you replied yes to the above questions, please answer the following question.
If you answered no please go to the next question.
I am having current thoughts of harming someone else without a plan or intent
I have current thoughts of harming others with a plan or intent to follow through
Do you have any history of psychiatric hospitalization?
*
No
Yes
If you replied yes to the above questions, please answer the following question.
When was your last psychiatric hospitalization?
MM
/
DD
/
YYYY
If you replied yes to the above questions, please answer the following question. What was the name of the psychiatric facility?
Your answer
Please select your preferred format for therapy sessions:
*
Telehealth: Prefer to meet via video call
In-person: Prefer to meet face-to-face
No preference: Comfortable with either
Please let us know your availability for therapy sessions. Select all times that generally work for you:
*
Tuesday Morning
Sunday
Thursday Morning
Tuesday Evening
Monday Afternoon
Saturday
Monday Evening
Friday Afternoon
Monday Morning
Thursday Evening
Wednesday Afternoon
Thursday Afternoon
Friday Evening
Wednesday Evening
Tuesday Afternoon
Friday Morning
Wednesday Morning
Other:
Required
Do you have any preferences regarding the therapist's demographics such as gender, age range, race etc.
Your answer
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