Journey4ward Counseling Appointment Request

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Appointment Requests: Journey4ward currently has a waitlist. Please be patient as we work through the requests for counseling. Typically, you will be contacted within 1 weeks. If you are not contacted within 1 weeks and need additional information, please email us at Journey4ward@yahoo.com or call 817-999-7784

Clients Name (First and Last Name) *

Guardians Name (if under 18 yrs) (First and Last Name)

What is the Clients date of birth? *

YYYY

Email Address (please use one that is checked often) *

Phone Number *

Zip Code *

Race *

White

Hispanic

African American

Multi Racial

Asian

Native American

Pacific Islander

Which option are you looking for? *

In Office Appointments

Tele Health

Either one (Telehealth or in office) will work

Which days and hours are best for you? *

Which therapist do you prefer? *

Bianca Camacho, LPC-A - Bilingual (Spanish), 8 yrs to adults, TELEHEALTH AND IN OFFICE, CBT, EMDR, Anxiety Disorders, Crisis Trauma, PTSD, Christian Counseling

Michelle McQueen, LPC-S - Bilingual (German), 4yrs to adults, TELEHEALTH AND IN OFFICE, CBT, EMDR, Crisis, Domestic Violence, Play Therapy, Cultural and Christian Counseling

Latisha Green, Psy.D., LBA, BCBA- Children 12 yrs to adults, Telehealth, in office, TELEHEALTH AND IN OFFICE, CBT, Anxiety Disorders, Crisis Trauma, PTSD

First Available therapist

Please select all that apply (victimizations) *

Adult Physical Assault

Adult Sexual Assault

Arson

Bullying (Cyber/Physical/Verbal)

Hate Crime (Religious/Sexual Orientation/Racial)

Sexually Assaulted as a Child

Child Physical abuse/Child Neglect

Child Pornography

Kidnapping (Non Custodial)

Kidnapping (Custodial)

Survivor of Homicide Victim

Terrorism (Domestic or International)

Burglary (Items Stolen but you were not present when burglary happened)

Robbery (You were present when this happened)

Stalking/Harassment

Domestic or Family Violence

Violation of Court Order

DUI/DWI Incident

Elder Abuse or Neglect

Vehicular Victimization (Road rage, hit and run, etc.)

Identity theft/Fraud

Human Trafficking (sex)

Human Trafficking (Labor)

Teen Dating victimization

At Risk Youth

Prison/Jail Reentry

Required

What brings you to counseling (Domestic Violence, homicide, sexual assault or abuse, Trafficking, general counseling, etc.), anything you would like therapist to know. *

Special Classification?

Deaf/Hard of Hearing

Homeless

LGBTQ

Immigrant

Refugee

Asylum Seeker

Cognitive Disability

Physical Disability

Mental Health Disability

Veteran

Limited English Proficiancy

Who were you referred by? (Name of friend, name of organization, found through web search, etc.) *

Have you applied for Crime Victims Compensation? *

YES

Not familiar with Crime Victims Compensation

Would like more information about Crime Victims Compensation

Are you interested in Support Group Sessions? *

YES

Required

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