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Help us learn more about you so that we may best match you with one of our highly qualified providers. We are offering therapy only at this time.

This is a HIPAA-compliant, secure form. We value your privacy, and access to your questionnaire is limited to our Client Care Coordinator and pertinent clinical staff of UCEBT.

Please look for the confirmation message at the end of your screen to ensure that your responses have been recorded.If for any reason you do not hear from us within 2 business days, please reach out to our Client Care Coordinator at (801) 419-0139 Extension 2. We look forward to connecting with you!

*If you are in need of immediate MH support or crisis intervention, please instead reach out to the National Crisis Hotline at 1-800-273-8255, call 911 or go to your nearest ER.

Is this screen for you or someone else? *
If you answered 'someone else', please provide your name and relation to the patient:
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Patient first name: *
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Patient last name:
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Phone number: *
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Patient date of birth: *
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Email address: *
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Would you like us to reach out by email if you are unable to reach you by phone? *
What is patient's biological sex? *
What is patient's gender identity? *
How did you hear about our clinic? *
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Please indicate any scheduling limitations:
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Are there any accommodations that would be helpful to address visual, hearing, physical or any other needs the patient may have?
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For more information about payment options, please see the Costs and Fees section on our website ( ).
Are you able to direct-pay? *
Our Center requires direct pay, where clients are responsible for full payment of services rendered at or before the time of service. A detailed receipt of services can be provided for submission to your insurance, for possible reimbursement.
Non-Licensed Providers and Sliding Scale
UCEBT is committed to increasing access to effective, affordable mental health care. To this end, we are excited to introduce our sliding scale psychotherapy clinic. These services are provided by advanced doctoral students, who have earned their Masters degrees and are currently under the close supervision of licensed psychologists. Please note that these sliding scale services are not reimbursable by your insurance provider. After discussing your specific financial circumstances and completion of our application, we will work collaboratively to provide options for adjusting our rates.
Are you open to seeing a doctoral trainee or post-doctoral fellow? *
UCEBT is contracted to provide Employee Wellness/EAP services (i.e. brief counseling covered by the employer) . Were you referred for this reason? If yes, please list your employer: *
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What type of services are you seeking? *
For more information on assessments, please visit the following section of our website (
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