Counseling Appointment Request

Emergency Assistance

If this is an emergency, call:

Suicide Hotline: (800) 273-8255
Emergency Services: 911

We can only provide counseling to individuals in the State of Indiana, Florida, and South Carolina at this time.

Client Information

First name

Last name

Best Name/Preferred Name

Pronouns

Date of Birth

Zip Code

Street Address

City

State

Email address

Phone number

Gender Identity

Ethnicity

Sexual Orientation

Race

Languages

Marital Status

Employment

Religious or Spiritual Affilitation

I'm a current/former client

Times Available to Meet

Select the days and times of availability Check all that you would be available

Sunday, Afternoon

Tuesdays, Afternoon

Tuesday, Evening

Wednesday, Evening

Thursday, Morning

Thursday, Afternoon

Friday, Morning

Friday, Afternoon

About Your Appointment

Type of Counseling you are seeking

Individual Counseling

Group Counseling

Describe the reasons you are seeking therapy.

Please be specific

Describe any goals or outcomes you hope to achieve from therapy

Are you or have you been suicidal in the last 60 days?

Yes, I am currently or have recently been suicidal, and I have attempted suicide before. Yes, I am currently or have recently been suicidal, but I've never attempted suicide before. No, I am not suicidal now, but I have attempted suicide in the past. No, am not suicidal and I have never attempted suicide.

Please check all of the following that you have available to you.

A safe, private place for counseling

A computer, iPad, tablet or phone that can handle Zoom

A stable internet connection.

If referred specifically to us, what is the referral and from whom?

Other information you would like us to know.

What is your household income? - Please specify if this is weekly or monthly. If your income fluctuates, what is the average?

How many people are you financially responsible for (spouse/minor children)?

Please attach a copy of your Drivers License or State ID.

If you are required to complete a specific type of counseling per court, probation, or another agency, please attach a copy of your paperwork.

Files

Add file

Please upload a file

We will reach out to schedule a brief appointment with you to determine if Telemental Health counseling is a good match for your needs. Please note that our office is closed Saturday, Sunday and Monday, but we do have limited appointments on the weekend at times.

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