UNCG Psychology Clinic - Client Interest Form

Please note it may be several days before you receive a response via phone. 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, Suicide & Crisis Line at 988, or the Therapeutic Alternatives Mobile Crisis Line at 1-866-626-1772

Name

First & Last Name of potential client

Name of person completing this form (if different)

Please include your name here if you are filling this form out for someone else (e.g., child, dependent)

Date of Birth

of potential client

Gender / Pronouns

of potential client

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

Individual Therapy (Adult)

Individual Therapy (Youth)

Group Therapy

Testing (Adult)

Testing (Youth)

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

Mailing Address

City

Zip Code

Are you affiliated with 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, via Sandhills or Trillium

Yes, via HealthyBlue

Yes, via 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 at this time. If you pay the full fees for services (e.g., no discounts or financial assistance), you can receive 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

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