TBF Counseling LLC | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

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Administrative

Referral source

Enter how you were referred to our services

What is your availability like? When would you like to schedule appointments?

E.g., I’m available Monday mornings; I need Wednesdays after 1 pm; etc.

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Billing & Payment

Payment method

How do you plan to pay?

Insurance details

What insurance(s) do you have?

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Client Preferences

Preferred modality

Reason for care

What are your main concerns or goals? What do you think I should know about you right now?

For example: what is bringing you to therapy (e.g., anxiety; depression; trauma; grief; life transitions; etc.); what you'd like to focus on; what do you hope to get out of therapy; insurance or payment question; etc.

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Have you seen a therapist before? If yes, what was helpful or not helpful?

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Any past or current mental health diagnosis/es? If yes, please note here.

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Any history of self-harm, suicidal thoughts, suicide attempts, or hospitalization for mental health? If yes, please note which of these and when.

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Do you use alcohol, tobacco, cannabis, or recreational drugs? If yes, what do you use, what frequency, and what quantity?

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.