Name *

First Name

Last Name

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)

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

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)