Beal Consulting and Counseling, PLLC Intake Form

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Thank you for choosing us as your provider. It is important that we gather some information so we best know your needs and desires for your clinician. Please complete the information below and an intake coordinator will contact you via phone or email to schedule and verify insurance coverages for your care.

What is your name? *

What is your email address? *

What is your physical address? *

What is your phone number? *

What is your birthdate? *

YYYY

Why are you seeking services? *

Are you using insurance or self paying? If using insurance, please include company and member number. *

With whom would you like to work? (select up to 3) *

Helen Seretis, LPC

Taja-Nia Horne, LPC, EMDR-T

Cashina Leary, LSW (IL/IN)

Jeanette Bledsoe, LSW

Bernita Thomas-Bishop, LSW

Kathryn Griffin, LSW

Tiana Shear, QMHP, EMDR-T

Juliana Ferrusquia, LPC, EMDR-T, Spanish speaking

Katherine Crocket, Interm

Abby Lenhoff, Intern

Required

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