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 *
Email *
Phone Number *
Birthday *
Please enter your insurance card or indicate if you will be a self-pay client. *
We are in-network with UnitedHealthCare, Cigna & Carefirst
Please provide insurance card number is you plan on using your insurance coverage.
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)
How did you find out about Distict Counseling *
If referred please enter the name of the referral source.
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