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Sankofa Referral Questionnaire
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First Name:  *
Last Name *
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Phone number :  *
Address:  *
email address ( Please verify your entry is accurate)  *
Date of Birth: *
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Gender : *
Referred by? *
Do you have an account number, authorization number, or voucher number? *
Do you have health insurance?  *
What health insurance type? *
What is your insurance member ID? 
If your insurance is not accepted, are you able to pay out pocket? Fees range from $185 & up per session. *
Do you have HSA or FSA to pay for therapy? *
Are you seeking counseling for yourself or someone else?  *
If seeking therapy for a minor do you have full legal custody? 
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Reason for seeking therapy services:  *
Have you ever been in therapy before? If yes, when were you last seen and for how long were you seen? *
Are you currently having suicidal thoughts or self-harming thoughts *
If you replied yes to the above questions, please answer the following question.   If you answered no please go to the next question. 
Are you currently having any thoughts of harming others? *
If you replied yes to the above questions, please answer the following question.    If you answered no please go to the next question. 
Do you have any history of psychiatric hospitalization? *
If you replied yes to the above questions, please answer the following question. When was your last psychiatric hospitalization? 
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If you replied yes to the above questions, please answer the following question. What was the name of the psychiatric facility?
Please select your preferred format for therapy sessions: *
Please let us know your availability for therapy sessions. Select all times that generally work for you:   *
Required
Do you have any preferences regarding the therapist's demographics such as gender, age range, race etc.
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