Pre-Consultation Form

Please correct the errors described below.

Emergency Assistance

If this is an emergency, call:

Suicide Crisis Line: 988
911

Information

*Please note we are a virtual practice in the state of Texas and you must be in Texas for services

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

How did you first come in contact with us?

Google Website Social Media (Instagram, Facebook etc..) Psychology Today Therapy for Black Girls Insurance Directory Family/Friend Referral Other

What are you seeking a consultation for?

Individual Work Couples Work Supervision Other

If seeking couples work complete following: Partner's Name and contact inforamtion

Can you tell us about yourself and what's making you seek guidance now?

What are you looking to achieve as we work together? (be as detailed and specific as possible, What's your vision or dream here? What would you define "success" as?)

How ready are you to start therapy? Rate yourself from 2 (not really) to 10 (I'm ready to start yesterday!)

2 4 6 8 10

Do you plan to use insurance or private pay? Payment options

Aetna Cigna Private Pay 4 for 4 Bundle Not Sure

If using insurance, Please upload a copy of your insurance card.

Add file

Please upload a file

Consent & Privacy Acknowledgment

By submitting this form, I understand that this does not create a therapeutic relationship and that a consultation is for informational purposes only.

I agree

Additional Notes

Your information will be encrypted.

Emergency Assistance

If this is an emergency, call:

Suicide Crisis Line: 988
911

Telephone 832-543-7255
nextstagecounseling.com
nextstagecw
nextstagecw

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