New Client Interest Form
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Your Name *
Email *
Phone Number
I prefer to be contacted by *
Could you share a little bit about why you’re seeking counseling?
Even vague categories are helpful.
Were you hoping to use insurance or pay out of pocket? 
Some of our providers accept Aetna, Anthem and Optum/United. Our session fees range from $25 to $150.
If you are hoping to use insurance, please let us know what insurance you have. 
If you do not have insurance or intend to use insurance, you can leave this blank. If you do have insurance that you hope to use, please indicate the name of the insurance company, and any other details about the type of policy it is.
Are you available for daytime appointments or do you need evening/weekend options?
Do you have a preference for meeting location? 
Select all that apply
Please give us a general indication of your age and stage of life. 
We find this information helps us make a good counseling match. Please select all that apply. 

NOTE: If you are filling this out for a dependent, please select categories that apply to the individual who will be receiving counseling. 
Any other concerns you want us to know about to help us make a good counseling match? 
For example, some people have a preference for a male or female counselor, or for a counselor of a certain age or ethnicity?
How did you hear about CrossRoads? 
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