UNCG Psychology Clinic - Client Interest Form

Please note: We aim to contact you via phone within 3 business days. You only need to submit your information on this form one time. Thank you for your interest!

If you are experiencing an emergency, please contact 911, or for a mental health emergency, please contact Suicide & Crisis Line at 988, or the Integrated Family Services Mobile Crisis Team at 1-866-437-1821.

Full Name of Potential Client

First & Last Name of person seeking services

Date of Birth

of potential client

Gender / Pronouns

of potential client

If you are completing this form on behalf of someone else, please indicate your name here

If requesting services for yourself, skip this box

Relationship to potential client (if not you)

Please indicate if you are a parent/guardian, referring provider (and what agency you're with), etc.

Referring Provider Phone Number

Skip if you are completing this for yourself/family

Referring Provider Email Address

Skip if you are completing this for yourself/family

The potential client is

A child or teen

17 and younger

An adult

Ages 18+

What services are you seeking? (Select all that apply)

Individual Therapy

Group Therapy

Testing / Assessment

Cognitive testing: N648 requested, if qualify

If the potential client does not speak English, please indicate language(s) spoken

There may be a slight delay to obtain an interpreter to contact clients in other languages; thank you for your patience!

Provide a brief (less than 10 words) description of why you are seeking services

Please note these forms are not monitored for safety concerns. If you are experiencing a mental health emergency, please contact 911; the Suicide & Crisis Line at 988, or the Therapeutic Alternatives Mobile Crisis Line at 1-866-626-1772 if you reside in or near Guilford County.

Email address

Phone Number

This is how we will contact you with more information

Mailing Address

City

Zip Code

Are you affiliated with UNC Greensboro (UNCG)? You are not required to be affiliated with UNCG to receive services with our clinic. We are happy to serve our Greensboro community. However, UNCG students, staff, and faculty are eligible for discounted rates.

UNCG Student

UNCG Faculty/Staff

Do you have Medicaid insurance? We have a limited number of providers who are credentialed with Medicaid

Yes, with Trillium

Yes, with HealthyBlue

Yes, but another option or I'm not sure

Unfortunately we do not accept any other forms of Medicaid at this time

We do not accept private insurance. Would you like to apply for financial assistance?

Yes

I understand I will need to provide financial information to apply for financial assistance

If you have private insurance and pay the full fees for services (e.g., no discounts or financial assistance), we can provide a Superbill that documents the services provided. Please contact your insurance company to learn if you may be eligible to receive reimbursement for "out-of-network" services.

I am a current UNCG student

UNCG students already receive the lowest rates

How did you hear about us?

Thank you for considering the UNCG Psychology Clinic!

Your mental health matters and we are glad you reached out. We look forward to connecting with you.

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