Tree of Hope Counseling Screening Form

We receive over 200 referrals each month here at Tree of Hope Counseling, and it speaks to just how great the need is in our community. No matter what, we want to make sure you feel supported. If we aren't the right fit, we'll share recommendations and resources so you're never left without a path forward.

Please complete the confidential screening form below. We do our best to get back to you within 7-10 business days while we work to match you with the clinician best suited to your needs. Thank you so much for your patience, and for letting us be part of your healing journey.

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Your Name *
Name of potential patient and relation to you (if other than self)
Age of patient *
Potential patient's ethnicity (optional)
Potential patient's gender identity (optional)
Potential patient's sexual orientation (optional)
Child's School District and School Name (if applicable)
How did you hear about us? (please be specific if doctor, school counselor, provider, etc - we like to express our appreciation to referral sources!) *
What type of therapy are you seeking? *
Are you seeking therapy or medication management? Please note: our providers prefer that clients who are seeking med management also be engaged in therapy. *
Required
What prompted you to reach out for counseling?  What are you seeking support with? Please share anything that may be helpful in making a therapist match.  The more information, the better to get a connection made!  (If the information you provide is limited, we may need to reach out to you for more info before considering a match!) *
If an individual match is not available at this time, are you open to hearing about support/therapy group opportunities related to your identified needs? (Ideally, your need for individual therapy would be re-assessed within the group, and could be initiated at that time.) *
Preferred Availability for Appointments (best days and times) **Let us know if you have any flexibility for daytime appointments on weekdays** *
What is your telehealth vs in-person session preference? *
Therapist Preference (Check all that apply) *
Required
Please select your insurance company - this information is on your insurance card. Each of our providers panel as individual providers with insurance companies, so insurance coverage varies across our group.  We do our best to match based on your insurance.  Select all that apply: *
Required
Please select the type of insurance plan you have (some of our therapists can only bill to certain types of plans): *
Required
Some of our therapists are private self-pay only. Is private pay an option? (**If you choose YES, private pay therapists will be considered as a match for you. You may be matched with a private pay provider if insurance-paneled providers are not available.) *
Phone number *
Email *
If you are matched with a provider, what is your preferred method of contact to connect? 
(Please note:  initial contacts re: status of your screening form will be via email, so be sure to check!)
 *
Confirmation
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