Forward Emotion Pre-Screen Intake Form
Hello there! Here at Forward Emotion, we know it takes courage to reach out and ask for help. Please take a moment to give yourself credit for getting started.

To make sure that Forward Emotion is a good fit for you, please complete this pre-screen intake form. If what you are looking for help with is something our providers are a good fit for, we will reach out to schedule a quick call to gather any more information we may require, answer any questions you might have, start the onboarding process and get you set up with your first appointment. If for some reason, our services aren't a fit for your needs, we will let you know and provide other referral options better fitted for your current needs.

Please note that you will receive a response as soon as we are able, usually within 24-72 hours, as this form is not monitored 24/7.
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Email *
Legal Name (first and last) *
Phone Number with Area Code *
Permission to receive communications from Forward Emotion (select all that apply):

Please note: Forward Emotion requires email communication for ease of access to our online portal, scheduling and necessary documents. We will not send spam or junk mail.
 *
Required
Are you 18 years or older? Note: Forward Emotion currently works with clients 18 years of age and older. If you are filling this form out on behalf of an adult, please know that we will need to speak directly with that person in order to set up appointments. *
Date of Birth *
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DD
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YYYY
Services that you are interested in (select all that apply): *
Required
Brief description of why you are seeking therapy. *
Are you currently experiencing suicidal thoughts or self harming behaviors? If yes, please call your local crisis line or 1-800-723-TALK (National Suicide Prevention Lifeline) or text HOME to 741741 to communicate with a Crisis Counselor. *
Are you currently in danger of domestic violence? If yes, call 911 or 1-800-799-7233 to reach the National Domestic Violence Hotline or text START to 88788. *
Is there anything else you would like Forward Emotion to know? *
How did you hear about us? *
Forward Emotion is in network with BCBS PPO/Choice plans and is accepting self pay clients at an hourly rate of $175/55 minute sessions. Which of the following applies to you?  *
Forward Emotion is NOT in network with Medicare. Which of the following applies to you?

Please note: Forward Emotion is unable to provide superbills to Medicare recipients as there is no out of network coverage. Also, if Medicare is primary and commercial is secondary, Medicare will deny and the secondary insurance will deny as well. 
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Please note that you will receive a response as soon as we are able, usually within 24-72 hours, as this form is not monitored 24/7.  We will do our best to get back to you as quickly as possible. We will email from intake@forwardemotion.com. We will call or text from 630.999.8192.
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