JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Adult Contact Information
Please complete the following information. Our Clinical Coordinator will review your information and respond as soon as possible.
PLEASE check your SPAM/Junk folders for email responses if you have not heard from us within three business days.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name of Adult Requesting Services
*
Your answer
Name of Adult Completing the Form (if different from Adult Requesting Services)
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Preferred Pronouns
*
He/Him/His
She/Her/Hers
They/Them/Theirs
My pronouns are not listed
Prefer not to say
Required
Occupation
*
Your answer
Type of Service Requesting
*
Individual Therapy
Testing/Assessment
Mindfulness
Parent Consultation
Marriage/Couples Counseling
Family Therapy
Group Therapy
Medication Management
Required
Reasons for Seeking Counseling (Please be specific as to your current needs to better help us know which therapist would be the ideal fit.)
*
Your answer
How did you hear about us?
*
Your answer
Any Additional Information
Your answer
Name of Partner (Required if seeking Marital/Couples Counseling)
Your answer
Email Address of Partner (Required if seeking Marital/Couples Counseling)
Your answer
Phone Number of Partner (Required if seeking Marital/Couples Counseling)
Your answer
I understand Summit Emotional Health is an out of network mental health provider and does not accept insurance. I reviewed the payment policies at
www.summit-eh.com/payment
.
*
Yes, I have read and understand the payment policies.
Required
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Health and Family Psychologists of Virginia.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
