Answer the questions below to get matched with a counselor(Your answers are confidential) Name * First Name Last Name Email * Phone * (###) ### #### What are you seeking counseling for? * Select all that apply Feeling down or depressed Overwhelmed or anxious Substance use Trauma Life Issues (relationships, stress, sleep, self improvement, etc) Child Teen Gender Support Other (describe in comment box below) Comments on what you're seeking counseling for Do you drink or use THC or other drugs (or have you in the past)? * Yes, I drink (or used to) Yes, I use marijuana (or used to) Yes, I use other drugs (or used to) No, I have never drank or used marijuana or other drugs Have you used opioids in the last 12 months? Yes No Are you currently pregnant? Yes No Type of Insurance * Select all that apply No insurance (self pay) Forward Health/Medicaid/Badgercare Health Insurance Medicare (people with a disability and/or over age 65) EAP (Employee Assistance Program) Other or not sure Name of Insurance * What are your expectations of a counselor? (check all that apply) A counselor who.... listens and helps me process my thoughts explores my past educates and teaches me skills challenges my thinking assigns homework helps me set goals I don't know other (describe below) Comment on counselor expectations How did you hear about us? * Internet search Referred by family/friend Referred by doctor Other (describe below) Comment on how you heard about us Anything you'd like to add... Thank you. One of our matching specialists will call you within one business day.
