Therapy Prescreen Name(required) Email(required) Phone(required) Date Of Birth(required) Briefly, what is bringing you to counseling? How long have you felt like this?(required) Are you having thoughts about hurting yourself/anyone else?(required) Select one option (Pick One Please) Yes No Has anything significant happened to increase these feelings recently?(required) Which therapist have you selected to work with?(required) Select one option Qiana Russell, MSSA, LISW Sara Bates, MSW, LISW-S Melinda Balliett MSW, LSW Angelique Porter MSW, LSW, LMT, Reiki Master Pretty Amagbakhen MSW, LSW Donte Hardy, MS, LPC Acacia Quaintance (only seeing EMDR clients) No Preference Have you done counseling before in the past?(required) Insurance/Self Pay Select one option Cigna Anthem BCBS OSU (student or staff) OhioHealthy Medical Mutual Aetna Caresource Self Pay Submit Thank You! Someone will reach out to you soon Δ Share this:TwitterFacebookLike this:Like Loading...
