Confidential Consult

IF YOU ARE SEEKING TO SCHEDULE AN APPOINTMENT, PLEASE COMPLETE

THE FOLLOWING FORM IS IF YOU ARE INTERESTED IN LEARNING MORE ABOUT SERVICES BUT NOT YET READY TO REQUEST AN APPOINTMENT.

Please fill out the following information to receive a free, email, preliminary consultation by a licensed mental health professional. This consultation is designed to help further clarify specific counseling needs, determine the appropriate type of counseling and answer any questions you may have prior to entering counseling.

This preliminary consultation is provided via email and confidential. Mental health professionals are bound by a code of ethics and legally responsible for maintaining confidentiality. While confidentiality is upheld, this consultation alone does not bind either party or represent entering into a therapeutic contract. You will be contacted within 48 hours by a licensed mental health professional.

Confidential Consultation

Name*
First Last
Age*
Relationship Status*
- Single
- Engaged
- Married
- Divorced
Number of children*
Ages of your children*
Email*
Phone*
Prefered contact method*
- Email
- Phone
How did you come to JH Family Solutions?*
Please let us know how you heard about us.
- Website - google search
- Medical Referral
- Referral from friend/family directly to JHFS
- Word of mouth, advertising
- other
I am interested in the following type of counseling:*
- Couple Therapy
- Individual Therapy
- Family Therapy
- Couple Intensive Retreat
- Not sure of best place to start
I have the following insurance carrier:*
- BlueCross/BlueShield
- Other
- None - self pay
- JH Mental Health Initiative
Presenting Problem
PreScreening*
Please indicate all that apply, either historically or currently, to help us better assess which type of therapy will best meet your needs.
- There is/has been substance abuse/addictions
- There is/has been physical aggression/abuse
- There is/has been an affair
- Other
Briefly describe what led you to contact us today*
How long has problem occurred?*
I have been in therapy previously for this issue*
Please indicate if you have had previous counseling relating to this issue
- Yes, I have attended individual counseling
- Yes, we have attended couple's counseling
- Yes, my partner has attended individual counseling
- None of the above apply
What makes the problem better?*
What makes the problem worse?*
Current Relational Issues*
Please identify if any of the following are currently active in your relationship.
- There has been/is an affair
- substance abuse/addiction
- Domestic Violence
- None of these apply currently
Outline any counseling goals*
Additional info you feel is important to know
Additional questions you have regarding the counseling process
Comments
This field is for validation purposes and should be left unchanged.

Confidential Consultation

Presenting Problem