Secure Inquiry

Contact's Information

Please use your legal name and accurate information.

First name

Last name

What name do you go by? (nick name)

Address (Street, City, State, and Zip)

City

State

Zip Code

Email address

Phone number

Date of Birth

Who are you seeking services for?

Myself Myself and another party (i.e., marital, family, etc.) My child (17 yrs or younger) My child (18 years or older) Another adult family member Other

For those seeking services on behalf of another party:

If the other party is a minor, I can only fully explore potential services with the minor's guardian(s).

If the other party is an adult (18 years or older), I cannot make arrangements for another adult with you. I can discuss general processes and provide basic information about services with any party that would like more information. The prospective adult client must contact my office directly to initiate any processes or services.

Are you a previous client of Dr. Mountain?

Yes No

OTHER PROVIDERS:

It's important that I have the following information to serve you well.

Please list all current and previous MENTAL HEALTH PROVIDERS from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)

Please list all current and previous MEDICAL PROVIDERS (MDs, PTs, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)

Please list all current and previous COACHES or OTHER HELPING PROFESSIONALS (Leadership, Life, Couples, etc.) from the last 5 years. Indicate which are current if applies. (Type 'NA' if none.)

Please tell me how you found my office?

Who referred you to AHA? (Type 'NA' if none.)

Seeking Services For:

Individual Counseling

(Texas & Florida)

Relationship Counseling

(Texas & Florida)

EMDR or ART

(Texas & Florida)

Sex Therapy

(Texas & Florida)

Coaching

Speaking & Training

(My media team will reach out in response.)

Other

Reason for seek services:

I understand that all services at Jenna Mountain, PLLC are by appointment only.

I understand.

Appointments/Phone Calls will be scheduled by appointment only.

If you are ever in a state of emergency, call 911 or go to the nearest emergency room for emergency services.

Emergency and immediate services are not services provided. The following local resources are alternative options for potential clients who find themselves needing higher levels of care:

EMERGENCY RESOURCES

Dallas County MHMR 877-283-2121
Tarrant County MHMR (817) 569-4300
Collin County MHMR Lifepath Systems (Collin County MHMR) (972) 562-0190
24/7 Crisis Text Line Text “NAMI” to 741-741
National Suicide Prevention Lifeline 1-800-273-TALK (8255) or 1-800-SUICIDE (1-800-784-2433)
Parkland Hospital Psychiatric Emergency 214-590-8000
SAMHSA's National Helpline. (800) 662-4357
The Turning Point Rape Crisis Center Crisis Line 1-800-886-7273
Dallas Area Rape Crisis Center (972)-641-7273
Hope’s Door 24-Hr Hotline (Collin County) (972) 276-0057
Family Place 24-Hr Crisis Line (Dallas County) (214) 941-1991
Genesis Women’s Shelter Hotline (214) 946-4357
Carrollton Springs 24 Hr Hotline (972) 885-3795

I agree to receiving communication from Dr. Mountain via email, phone, and/or her EHR system to prepare for any process or services; and understand that those emails will be encrypted. Dr. Mountain primarily communicates with clients via email, phone, or through her EHR system. Her emails are encrypted via Hushmail. Email is reserved for scheduling and administrative purpose only. Please note that I do not provide therapeutic support or services via email, phone, or through her EHR system. If you are experiencing a crisis, please contact your local emergency services.

I agree I disagree

Do you have health insurance? Mental health providers are required by law to ask if you have insurance. Dr. Jenna Mountain is a fee-for-service, private practice that is not paneled nor participates with any insurance companies.

Yes No

Are you eligible for Medicare Benefits? Mental health providers are required by law to ask if you qualify for Medicare. Dr. Jenna Mountain is a fee-for-service, private practice and does not participate in Medicare as a provider.

Yes No

Dr. Jenna Mountain does not currently participate as a provider with insurance plans or Medicare, and is a fee-for-service, or private pay, practice.

Please review my website for full explanation.

Verification of Information I agree and verify that I, the named above, have completed this form and by submitting this form, I acknowledge that the information provided is accurate to the best of your knowledge.

I agree and verify

I agree to being contacted by Jenna Mountain, PLLC. I acknowledge and consent to be contacted at the information provided in this form by Jenna Mountain, PLLC

I agree and consent

I understand I will have the opportunity to schedule my own Phone Consultation. After submitting this form you will be redirected to a scheduling page. There you will be able to schedule a brief Phone Consultation with Dr. Mountain at your convenience. You will also receive a follow up email that will also offer the option of scheduling the phone consultation. Phone consultations that are scheduled without the completion of this form will be canceled until an inquiry form is completed.

I understand.

Jenna Mountain, PLLC uses Hushmail as a confidential, HIPAA compliant email service.
This services requires the uses of a secure portal to view and respond to any emails.

Your information will be encrypted.

Secure Inquiry

OTHER PROVIDERS:

Appointments/Phone Calls will be scheduled by appointment only.

Jenna Mountain, PhD, LPC, CST