Your First Name
Your Last Name
What type of support are you seeking?
For whom are you seeking support?
Me and my partner/family
A child in my care
If you will not be the client, please give us their first and last names.
How can we support you/your family? (Why are you seeking treatment?)
Anxiety and/or Depression
Work and Career Counseling
Work Related: Burnout/Secondary Traumatic Stress/Vicarious Trauma
Referral from physician, other health professional, EAP
Availability: Which days and times are best for appointments?
If you have a gender, age, sexual orientation, modality or specialty preference please list below. If you do not have a preference please state "no preference."
Do you plan to use insurance for treatment?
If you would like to partially pay 'out of pocket' for treatment please select your insurer and "I will pay out of pocket."
Alameda Alliance/ Beacon Health
Anthem Blue Cross
EAP (i.e. Claremont, New Directions etc.)
Victims of Crime (VOC)
I will pay out of pocket
How did you hear about us?
Referral from a college/university
Referral from employer or EAP
Referral from insurance provider
Referral from medical provider
Word of mouth
Is there anything additional that you want us to know?
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This form was created inside of Sankofa Holistic Counseling Services.