Name
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First Name
Last Name
Preferred pronoun
Email
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Phone
(###)
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Primary Reason(s) for seeking support?
Do you have a specific clinician you are interested in working with?
This is not necessary, as our scheduler will support in matching you.
Are you planning to utilize insurance?
Insurance provider:
Insurance Type
Where is your insurance plan from?
If we do not have clinicians available (or taking intakes) that accept your insurance, are you interested in seeing a clinician utilizing a reduced sliding scale?
Interns have a sliding scale starting at $25
If fully vaccinated, do you have an interest / desire to be seen in person after the intake? This will depend on the clinician. At this time many are remaining fully virtual.
Note: Both clinician and clients are required to be fully vaccinated to be in the office. In person availability varies by clinician. Clinicians will discuss this on or after intakes.
Special or restrictive availability (days and times?)
Note: We have very limited availability for intake slots. We will do our best to accommodate needs
Can you provide one sentence on why you are reaching out for services today and what you are hoping to obtain from services?
Is there anything else you think it would be important to know to match you with a clinician?
Some of our clinicians have opened slots specifically for those that identify as BIPOC. Please let us know if you identify as BIPOC by checking this box.
How did you hear about Forward Wellness?
Disclaimer
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Availability Notice
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