Name *

First Name

Last Name

Phone

(###)

###

####

Do you identify as a member of a racial/ethnic minority, sexual/gender minority, or over the age of 65? *

Yes

No

Do you currently have insurance that covers mental health treatment? *

Yes

No

I'm not sure

Are you able to afford weekly counseling sessions with your current insurance copay? *

Yes

No

I'm not sure

Not applicable

Terms *

By filling out this form, you understand that your request for mental health services does not guarantee immediate services or placement with a therapist at Forage Wellness Collective. While we strive to do our best to provide timely communication and services, other factors including your mental health needs, goodness of fit with one or more of our therapists, your location, and our therapist's current availability may also affect our ability to proceed with counseling services on your behalf.

I understand