Intake Form Welcome to Hand in Hand Counseling! Please fill out the information below so we can pair you with the right member of our team. Our aim is to provide you with the highest level of support throughout your journey. First Name Last Name Email Address Name of Person Completing the Form Relationship to Client Phone Number Client’s DOB Preferred Therapy Setting In-Office Virtual All Hand in Hand Counseling therapists have unique specialties and areas of expertise. To ensure that we match you with the most appropriate clinician, please select your areas of concern: Academic or Learning-Related Challenges Addiction ADHD Anger Management Anxiety Autism Bipolar Disorder Chronic Illness or Pain Depression Eating Disorder Family Conflict Gender Dysphoria Grief Identity (Racial, Sexual, Gender, Religious) Obsessive-Compulsive Thoughts/Behaviors (OCD) Parenting Challenges Relationship Issues or Divorce Self-Esteem Sleep or Insomnia Spirituality Stress Trauma Women’s Issues Other: Do you wish to use insurance? Please note that we do not currently accept Medicaid, Medicare, or TRICARE plans. Eligible EAP and employee benefit plans are welcome. Yes. I have verified that Hand in Hand Counseling is in-network with my plan. No, I wish to be self-pay. I understand that appointments are $140/hour. I'm not sure. I would like assistance verifying my benefits. Please provide the client’s sex as it appears on their insurance records Female Male Do you have a preferred appointment time? (Select all that apply) Mornings (8am-11am) Early Afternoon (12pm-2pm) Late Afternoon (3pm-5pm) Evenings (after 5pm) No preference. I'm flexible! Do you have a preferred appointment day? (Select all that apply) Monday Tuesday Wednesday Thursday Friday No preference. I'm flexible! Is there anything else we should know? Submit
