Intake Questionnaire
Thank you for being interested in our Counseling Services! Please fill out the following questionaire and we will respond to you with some available openings within one business day. 
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Please provide the name of the person completing this form: *
Please provide your phone number: *
Please provide the best email address to contact you: *
I want an appointment for... *
Required
Client's first & last name *
What is your relation to this person?
Client's birth date *
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Which locations were you interested? (Select all modes you are open to) *
Required
What are some presenting issues or things you are hoping to address in therapy?  If you chose "family therapy" please disclose each family members' ages and relations in the description. *
Theraputic relationships are similiar to other relationships in one's life, and we want to make sure we find a good fit for you. What are preferences or qualities that you are you looking for in a therapist? (It's also okay if you're not sure!)
Available days for the appointment (Select one or more) *
Required
When are you available for an appointment start time? (Select all that are applicable for you) *
Required
How did you hear about us? *
Are you interested in using a medical insurance plan or be a self pay client? *
If you have Medicare, what is your supplemental or secondary insurance?
Has the client seen any other Mental Health Provider this year? *
Is the client currently in a PHP, IOP, or other residential program? *
If using insurance, please select your primary insurance carrier that we are in-network providers with: *
Do you have a secondary insurance that you would like to use in addition to your primary insurance? *
What is your preferred method of contact? *
Required
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This form was created inside of Bellosa Counseling, LLC.