Please note that all intakes are virtual telehealth appointments. Clients must be a resident of PA.Schedule an Intake Name * First Name Last Name Preferred pronoun Email * Phone (###) ### #### Primary Reason(s) for seeking support? Anxiety/ Depression Trauma Grief Relationship (for individual) Pregnancy Postpartum Infertility Reproductive Loss Reproductive Trauma Childless Family Exploration LGBTQIA+ Family Building Queer Celebrating Support Transgender/ Gender Identity Care Neurodivergent Exploration and Acceptance (we do not do coaching) Race/ Identity Related Trauma Couples (seen as a couple) 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? Yes No Insurance provider: UPMC Healthplan Cigna Highmark Other Blue Cross/ Blue Shield plan Optum United Behavioral Health Aetna Other Insurance Type Where is your insurance plan from? Employer Sponsored Plan Marketplace Purchased Plan Medical Assistance (Medicaid) MUST be through Allegheny County Medicare MUST be through Allegheny County 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 $45 Yes No 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. Yes No How did you hear about Forward Wellness? Disclaimer * By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Forward Wellness harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means (Squarespace). All future communication will be completed via a HIPAA secure platform. If you wish to avoid using this form - please utilize our HIPAA complaint email by messaging Lorie directly at Lorie@forwardwellnesscounseling.com Availability Notice * We are so glad you want to work with us! We will do our best to meet your priorities regarding utilizing insurance, preferred clinicians, time availability, etc. We will do our best to accommodate you, and offer other options as needed.. Thank you for your submission. We will be in touch with you by email as soon as possible.
