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ShorelineCBT Appointment Request Form
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Client Name (If minor, please also state guardian name)
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Date of birth
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Preferred phone number
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Preferred email
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What is your availability for appointments?
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If you are planning to use insurance, what is your insurance plan (Carrier and Member ID)
Your answer
In order to best match you with a provider who would meet your needs, can you please share your reasoning for seeking out counseling?
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Do you have a history of substance abuse/use? if yes, please specify.
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Do you have a history of legal issues? If yes please specify.
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Do you have a history of hospitalizations for any mental health reason. If yes, when?
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How did you hear about ShorelineCBT?
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Is there anything else you would like us to know?
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