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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.
* Indicates required question
Email
*
Record my email address with my response
Full Name
*
Your answer
Email
*
Your answer
Phone Number
202.630.2129 - format
*
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 & Aetna)
*
United Health Care
Cigna
CareFirst
Aetna
Out-of-Pocket
Other:
Required
Please provide your insurance card number if you plan to use your insurance coverage.
(
Add insurance card number only)
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
What issues are you currently seeking services for?
(Please check all that apply)
*
Anxiety
Depression
Grief & Loss
Stress
Neurodivergence Supports (ADHD, Autism)
Trauma / PTSD
Relationship Issues
Work-Related Stress / Burnout
Anger Management
Other:
Required
How long have you been experiencing these issues?
Less than 3 months
3–6 months
6–12 months
Over a year
Other:
Clear selection
What type of services are you seeking?
(Please check all that apply)
Individual Therapy
Family Therapy
Couples Therapy
Group Therapy
Support Groups
Other:
Have you previously sought therapy or mental health services?
If yes, pleas
e provide brief details in the others section:
Yes
No
Other:
Please indicate your availability for therapy sessions.
Select all days and times that generally work for you:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Weekends
Morning (8:00 AM – 12:00 PM)
Early Afternoon (12:00 PM – 3:00 PM)
Late Afternoon (3:00 PM – 6:00 PM)
Evening (6:00 PM – 9:00 PM)
Other:
Required
How did you find out about District Counseling
If referred, please enter the name of the referral source.
Your answer
Additional Notes, Comments & Preferences
Your answer
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