Client Information Screening Form

Disclaimer: Completing the Contact Us form or Screening form does not mean that you are a client or will become a client of Black Therapist & Company. If you are having thoughts of hurting yourself or someone else, please call the Suicide hotline at 800-273-8255  or 988- 24/7. 

Please enable JavaScript in your browser to complete this form.

Please fill out the following questions to help us understand your needs and determine if we have a provider to meet those needs.

Name *

First

Last

Email Address *

Are you seeking individual sessions for yourself, family, or individual sessions for each of your children? *

• Myself
• Family
• Couples
• Individual sessions for child/children

Child/Children's ages: *

Any current and/or history of self harming attempts or thoughts? *

• Yes
• No

Important: We are not set up for 24hr support or high-risk services.

Do you currently use, or have you ever used, alcohol or drugs in a way that has caused concerns or problems for you? *

• Yes
• No

soon If individual

We are moving toward a primarily self-pay payment model. At this time, we still accept insurance for clients in Oregon and some clients in Washington. We are in-network with Blue Cross Blue Shield, MODA, Kaiser, PacificSource, and CareOregon/Health Share/OHP. Will you be using any of these insurance plans? *

• Yes
• No

If yes, specify which one: *

Do you live in the state of Oregon, Washington, Texas, or New York? *

• Oregon
• Washington
• Texas
• New York

How soon are you hoping to start counseling? *

• Within the next week
• Within the next 2 weeks
• Other

If Other, please specify: *

Please provide multiple options for days/times you are available for sessions: *

Please provide as many options as possible.

Are you comfortable with virtual sessions via a HIPAA-compliant VIDEO platform? We are not offering in person sessions. *

• Yes
• No

In one sentence, please share what you are looking to work on in counseling: *

Do you have preferences for a provider? (Gender identity, cultural background, language, etc.) *

How did you hear about this practice? *

• Referral from a friend/family member
• Online search
• Social media
• Other

If Other, please specify: *

Submit