Tree of Hope Counseling Screening Form
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 4-5 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!!
Name of potential patient and relation to you (if other than self)
Age of patient
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? Please share anything that may be helpful in making a therapist match. The more information, the better to get a connection made!
Preferred Availability for Appointments (best days and times)
Please indicate your insurance situation. Each of therapists panel as individual providers with insurance companies, so insurance coverage varies across therapists. We do our best to match based on your insurance. Select all that apply:
Child Health Plus
Excellus Blue Cross Blue Shield
Excellus Blue Choice
Excellus Blue Choice Option
Excellus Blue Point
Medicaid (non HMO)
Some of our therapists are private self-pay only. Is private pay an option? (If yes, private pay therapists will be considered as a match for you.)
Yes private pay fee is an option if the best match for me cannot bill my insurance
No, private pay is not an option
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.
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