Consultation & Interest Form

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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, and all information that 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 I am able to accept new clients, and if so, to schedule a free 20-30 minute consultation.

Thank you!

Full Name *

Preferred 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 (please include provider's name in "additional information" box at bottom of form)

Psychology Today

Google/online search

I've worked with Beth before

I saw a business card somewhere

Other (please add details in "additional information" box at bottom of form)

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

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