Tree of Hope Counseling Screening Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Did you know that we get over 200 referrals per month?? The need is significant in our community and we are honored to be a part of your journey. We do our best to respond and connect you. If we aren't able to connect you, we want to give you options and recommendations outside of our group. Thank you for choosing us to start your journey toward healing.

Please complete this screening form. We do our best to get back to you within 7-10 business days 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!!

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 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.) *

Yes (if an individual provider match is not available at this time, group options will be shared)

No (only individual provider matches will be shared)

Preferred Availability for Appointments (best days and times) **Please note: As of 11/1, most of our affiliates have limited or no evening availability. Let us know if you have any flexibility for daytime appointments on weekdays** *

What is your telehealth vs in-person session preference? *

I want telehealth options only.

I want in-person options only.

I would prefer in person, but would be open to telehealth options if in-person is not available.

I do not have a preference of telehealth or in-person.

Therapist Preference *

Male

Female

Doesn't matter

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: *

Aetna

Excellus Blue Cross Blue Shield

Excellus Blue Choice

Excellus Blue Choice Option

Excellus Blue Point

Fidelis

Medicare

MVP

Cigna

TriCare

United

Empire

Oxford

Other:

Required

Please select the type of insurance plan you have (some of our therapists can only bill to certain types of plans): *

Commercial (through an employer)

Medicaid/HMO/NYS Marketplace (income-based, uses CIN#)

Medicare (disability based or over age 65, federal government plan)

I don't know which type of plan I have (we may reach out to try and help!)

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.) *

Yes, private pay fee is an option if the best match for me cannot bill my insurance

No, private pay is not an option

Phone number *

Email *

Confirmation

By submitting this form, you consent to your information being transmitted through the internet to our records. And like any other internet-based system, we do our best to protect your information.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms