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 of client and relation to you (if other than self)
School District and School Name (if applicable)
How did you hear about us? (please specify internet, doctor school provider, etc.)
What are you seeking support with? Please include anything that would be helpful to know in determining a therapist match.
Preferred Availability for Appointments (best days and times)
Please indicate your insurance situation. Insurance coverage varies across therapists, 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 the therapists are private pay. Is private pay an option? (If yes, private pay therapists will be considered as a match for you.)
Yes, I have an HSA I could use for a private fee
Yes, I could use other payment for a private fee
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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