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District Counseling Client Intake Form
Thank you for your interest in therapeutic services. Please complete this questionnaire in its entirety & once completed you will be contacted by a member of the District Counseling team with details on next steps.
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Full Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Please enter your insurance card or indicate if you will be a self-pay client.
*
We are in-network with UnitedHealthCare, Cigna & Carefirst
United Health Care
Cigna
CareFirst
Aetna
Out-of-Pocket
Other:
Required
Please provide insurance card number is you plan on using your insurance coverage.
Your answer
Current State of Residence
*
(Please Note: In-network insurance coverage is only available to DC, MD & VA residences, Cash pay/Out-of-Pocket are required for all non-local clients)
Your answer
How did you find out about Distict Counseling
*
If referred please enter the name of the referral source.
Your answer
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