New Client Information / Waitlist Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is for potential clients seeking to be contacted when space opens up at Compass Professional Counselors LLC., located at 359 S Mountain Blvd., Mountain Top, PA 18707. Clinician availability varies depending on many factors. Completion of this form indicates your desire to be placed on a waitlist and in no way starts or guarantees services.

Visit our website for more information regarding accepted insurances, our team, and services we provide.

*Please fill in all required fields and be sure to click "Submit".

Today's Date: *

YYYY

Client Name: *

DOB: *

YYYY

*If under 18, parent/guardian name:

Phone: *

Address: *

Email:

County of Residence *

Describe your reasons for seeking counseling at this time: *

My availability for 60 minute sessions is: *

Weekday Mornings (before noon)

Weekday Afternoons (between 12p-5p)

Weekday Evenings (wait times will be longer)

Weekend Mornings (before noon)

Weekend Afternoons (between 12p-5p)

Required

Insurance Type (ex: Geisinger Health Plan, Highmark BC/BS) *

Member ID & Group Number (some insurance cards do not list a group number) *

Insured Name & DOB (the person who holds the insurance policy) *

Is virtual an option? *

Yes

Please check to indicate understanding of the following: *

Waitlist times vary and it may take several weeks to receive contact.

I am agreeing to be contacted when a spot opens.

I understand that completion of this form does not guarantee services.

Required

Is there anything else you'd like us to know?

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Compass Professional Counselors.