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 $25
Yes
No
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.
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..