Matching Questionnaire

A good clinical and personality fit between a clinician and a client is key to a successful therapeutic relationship. Please take your time in filling out this form. Upon receipt, your form will be thoroughly reviewed and if you are found to be a good match for our practice, you will be contacted shortly (usually within 48 hours).

Name

How did you hear about us?

I understand that appointments are only available between 8am - 230pm, Mon - Fri

Yes

I plan to pay for my sessions via:

Blue Cross Blue Shield Insurance

Optum Insurance

Out of Network (OON) insurance benefits

Private Pay

I prefer to meet:

Online via telehealth only

In-person only

Mixture of both

What are you looking for help with? (situations, goals, symptoms).

Describe your current and previous psychiatric & medical history. (Include diagnoses, hospitalizations, and medications).

Describe any current or previous safety concerns (suicidal thoughts or actions, self-harm, or violence)

Describe your current and previous relationships with substances (including alcohol, marijuana, and any other drugs)

How do you currently cope with your challenges? What has been helpful, or not helpful, in the past?

Is there anything else you think we should know?

Thank you for taking the time to complete this form. We will be in touch soon.

Matching Questionnaire : Contact