Tree of Hope Counseling Screening Form
Please complete this screening form. We do our best to get back to you within 48 hours of your submission, and this is pending reaching out to our clinicians regarding their fit with your needs. Thanks in advance for your patience while we customize your care!!
Name *
Your answer
Name of client and relation to you (if other than self)
Your answer
Age *
Your answer
School District and School Name (if applicable)
Your answer
How did you hear about us? (please specify internet, doctor school provider, etc.) *
Your answer
What are you seeking support with? Please include anything that would be helpful to know in determining a therapist match. *
Your answer
Preferred Availability for Appointments (best days and times) *
Your answer
Therapist Preference *
Please indicate your insurance situation. Insurance coverage varies across therapists, select all that apply: *
Required
Some of the therapists are private pay. Is private pay an option? (If yes, private pay therapists will be considered as a match for you.) *
Phone number *
Your answer
Email *
Your answer
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