Gender: *

How do you prefer we contact you? (check all that apply) *

Text

Phone Call

Employment or Student Status *

Full Time

Part Time

Student

Occupation or School Name

How did you hear about our practice? *

Provide the name of the person or place who sent you to us. *

What are your goals for counseling at this time? *

**If you do not have your insurance card available to upload, please note that we will not be able to schedule you until we have the information.

Name of your insurance company: *

Please upload the front and back of your insurance card

Relationship to Policy Holder *

Policy Holder Name *

Policy Holder Date of Birth *

Policy Holder's Employer *

If you are not the primary policy holder, will we be billing you or the primary policy holder for any co-pays/deductibles/or session costs?

What type of Medicaid product are you covered under?

Your insurance will be out-of-network. We are not contracted with any Medicaid or Medicare products. If you choose to see one of our licensed independent therapists, you will be unable to submit to your insurance for reimbursement. We offer lower-cost options for those with Medicaid/Medicare/Tricare or uninsured. Our Psychology Residents are supervised by our Psychologists on staff to provide expert care while being able to receive care at a more affordable rate. Our regular 55 minute therapy sessions will cost $25-$40 if you see one of our Psychology residents who are currently in a doctoral program seeking their clinical psychology degree. We are unable to agree to single case agreements. If you are interested, we can provide more information. Would you like to continue with requesting an appointment?

Your insurance will be out-of-network. We will provide Superbills (receipt) for you to submit to your insurance company. You are responsible for the full rate of our services on day of service, and some insurances will reimburse for out-of-network services. We are happy to provide superbills and help you navigate how to initiate submission for out-of-network reimbursement if you choose to schedule with us. We offer lower-cost options for those with commercial insurance who are out-of-network if you see one of our supervised therapists if our regular self-pay rates are not feasible. These supervised therapists are either post-degree who are being supervised by one of our experts to obtain hours for licensure, or currently in a doctoral program seeking their clinical psychology degree. The rates for 55 min therapy sessions range from $75-$185 for out of pocket expenses. We are unable to agree to single case agreements. If you are interested, we can provide more information. Would you like to continue with requesting an appointment?

Do you struggle with any eating, weight, or body image concerns? *

Are you trying to control your weight or intentionally lose weight in any way? *

In what ways do you try to control your weight with food? Select all that apply.

I am dieting or trying to eat less.

I skip meals

I count calories

I avoid certain foods or food groups

If you answered yes to any of the above, how often does this occur?

On a typical day if you are trying to control your weight or eat less, what do you eat? *

Do you feel uncomfortable with/avoid foods due to taste, texture, or presentation or have a fear of vomiting or choking? *

I avoid foods because:

I worry about choking or vomiting when eating

I have a lack of interest in food

I don't like physical sensations (texture) of certain foods

Other

On a typical day, what do you eat?

Do you ever feel out of control when eating? *

In thinking about the last two to three weeks, on average how often has this occurred?

Are any of the below statements true?

I eat more than others think would be a normal amount of food.

I eat more quickly when I feel out of control.

I eat in secret or hide evidence of eaten food.

I eat in response to stress.

None of these statements are true.

Do you ever struggle with intentionally vomiting after eating? *

How often have you vomited in the last month?

Do you take laxatives and/or diuretics to lose weight? *

How often have you taken laxatives or diuretics in the last month?

Are you currently exercising? *

How often do you exercise?

Which of the following statements are true regarding exercise?

I exercise to lose weight.

I feel compelled to exercise.

I exercise to compensate for what I've eaten.

My friends or family think I exercise too much.

I exercise for stress relief/to improve mental health.

None of the above.

How much has your weight changed in the past 3 months? (Please indicate whether it is an overall weight loss of gain, if applicable) *

Have you experienced any of the following in the last month? *

If you indicated any physical symptoms in the last month, please describe them in more detail here (if you have an associated diagnosis related to the symptoms, please share here).

Primary Care Physician Name

Primary Care Physician Phone

Primary Care Office Name

Does your doctor have any concerns about your health? *

If your doctor has expressed concerns about our health, please list the concerns they have shared with you.

Are any of your medical providers prescribing weight loss medications? If yes, please describe

If you currently see a dietician/nutritionist, what is their name and telephone number?

Do you struggle with any of the following mental health concerns? *

If you struggle with any of the above, what would be helpful for us to know?

Do you struggle with thoughts to end your life or hurt yourself in some way? *

How frequently do you struggle with these thoughts?

Have you ever acted on these thoughts?

When was the last time you acted on these thoughts?

Have you every been hospitalized because of any self-harming behaviors?

If so, when and where were you hospitalized?

Are you on any medications for mental health concerns? *

If yes. what medications are you prescribed and who prescribes these medication (please list the physician name and telephone number)

Have you recently been in treatment for alcohol or substance abuse, or do any of your friends or family have concerns about your use? *

Please describe your struggles with alcohol or substances and what treatment you have received for these issues.

Are you currently seeing a therapist for any mental health concerns? If so please provide their name and phone number.

Which days of the week are you available for appointments? *

What times of the day are you available for appointments? Please note that our after school and evening appointments are limited and highly requested, therefore more flexibility in your availability will help us be able to schedule you as quickly as possible. We are happy to provide school and work excuses if you need one. *

Early Morning: 8:00AM - 10:00AM

Late Morning: 10:00AM - 12:00PM

Afternoon: 12:00PM - 3:00PM

Late Afternoon 3:00PM - 5:00PM

Early Evening: 5:00PM - 7:00PM (please note, you may be placed on a waitlist if this is the only time requested.)

Do you foresee any changes to your availability that might make a difference in your ability to schedule appointments? (changing jobs, starting school, moving out of state, changing insurance, etc.)

If you foresee any changes, what might they be and when might they occur?

Do you prefer virtual or in-person appointments? *

Do you have a specific clinician in mind? (please note certain clinicians may have a short wait list) *

If yes, which therapist(s) are you interested in scheduling with? (If they are not available, we may suggest another therapist based on your answers).

Is there anything else that you are struggling with you that you would like us to know?

If you are agreeable, which sessions would you be open to having a resident observe? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.