Consultation & Interest Form

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

Thank you for your interest in working with Beth at Supportive Connection Counseling!

Please fill out all the required fields below. If a question does not present an accurate answer for you, then please select an answer that is the most accurate or closest to your circumstances; there is space provided at the end of the form for additional information.

Your privacy is of utmost importance: all information you submit is confidential and protected. This form is solely for the purpose of establishing initial contact, understanding your needs, and confirming other requirements to work together.

After submitting this form, please allow me 1-2 business day(s) to respond. I will reach out to confirm if we are able to start working together and to schedule a free 20-30 minute consultation.

Thank you!

Full Name *

Gender Identity *

Male

Female

Other

Prefer not to disclose

Age *

Pronouns

Email Address *

Phone Number *

What are your current concerns that you're hoping to explore/address during our sessions? *

How are you planning to pay for services? *

Private / self pay [cash, check, or debit/credit card]

Aetna [Insurance]

Aetna Medicare Advantage Plan [Insurance]

Anthem Blue Cross Blue Shield [Insurance]

Anthem Medicare Advantage Plan [Insurance]

Carelon Behavioral Health [Insurance]

Colorado Medicaid [Insurance; Rocky Mountain Health Plans or Northeast Health Partners]

Kaiser (for northern CO residents) [Insurance]

Kaiser Medicare Advantage plan (for northern CO residents) [Insurance]

Medicare Part B [Insurance]

Optum [Insurance]

Tricare [Insurance]

TriWest [Insurance]

United Healthcare [Insurance]

United Healthcare Medicare Advantage Plan [Insurance]

Required

How did you hear about Supportive Connection Counseling? *

Directly referred by another provider/therapist

Psychology Today

Google/online search

I've worked with Beth before

I saw a business card somewhere

Other / I don't remember

Additional information: This is not a required field, but please add any information that you feel is important/relevant.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Supportive Connection Counseling.

Does this form look suspicious? Report

Forms