The Women's Center – Sign up for counseling

Tell us about yourself

Name*

First Last

Birthdate*

Gender

How would you describe your marital status?

Married
Partnered
Single

How do you define your race / ethnicity?

Spoken language

If not English, what language would be best for counseling? We will try to accommodate your language preference.

Do you identify as having a disability?

Yes
No

If yes, would you mind sharing more about your disability?

Are you looking for help with your disability?

(e.g., social security app, job training)

Yes
No

How did you hear about us?

Contact information

Address*

Street Address Address Line 2 City ZIP Code

County

Cell Phone Number*

Secondary Phone Number (Work or Home)

Email*

Enter Email Confirm Email

Best way to contact*

Phone
Email

Best Times to Contact

Best days / times for appointment

What days / times can you come to The Women's Center to receive personal counseling?

Is it safe to leave a voicemail message?*

Yes
No

Please tell us why it is not safe to leave a voicemail message.

Emergency Contact Information

Whom do we contact in case your phone is turned off or in case of an emergency? (They do not need to live in the state. The most important thing is that you feel comfortable telling this person that you are coming to The Women's Center for counseling.)

Emergency Contact's Name

Emergency Contact's Phone

Insurance Information

Do you have health insurance?*

Yes
No

Are you interested in getting health insurance coverage?

Yes
No

Are you interested in using health insurance to cover therapy?*

Yes
No

Primary Insurance Company Name*

Customer Service Phone Number*

Insured ID#*

(NOT Group ID#. Typically starts with letters, e.g. ZYX000123456)

Are you the policy holder?*

Yes
No

Policy holder's name*

First Last

Policy Holder's Date of Birth*

What is your relationship to the policy holder?*

Partner
Child

Income

If you are not using insurance, we will use this information to help set a rate you can afford on a weekly basis.

Do you provide most of the income for your household?

Yes
No

How many people are in your household?

Estimate your monthly income:

Reasons for seeking counseling

If you are comfortable, please share some of the reasons you are looking for counseling at this time.

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