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Client First Name

Client Last Name

Client Date of Birth (YYYY-MM-DD)

Name of Person Completing This Form

Relationship to the Client

Phone Number

Do you currently reside in the state of Louisiana?(required)

Yes No I am currently on military orders

What brings you to counseling?

Type of counseling you are looking for (select all that apply):(required)

Individual Counseling (Adult: 18+) Family Counseling (Up to 6 participants) Relationship Counseling (2-3 participants)

How would you like to meet for counseling sessions?(required)

What days of the week are you available? (select all that apply)(required)

What time of day do you prefer? (select all that apply)(required)

Morning (9am-11am) Afternoon (12pm-3pm) Evening (4pm-5pm)

How often would you like your sessions to be?(required)

Every Week Every Other Week

Do you plan to use your health insurance to pay for Individual Counseling?
(Please note: PLPCs do not accept insurance. Family Counseling and Relationship Counseling are NOT covered by any insurance plans. These services are private-pay only.)(required)

Yes No, I plan to pay the private-pay rate No, I would like to discuss other payment options I'm not sure

If you plan to use your health insurance for counseling, what company is your plan with?

If “other” please explain.

Are you the insurance policy holder?(required)

Yes No, my parent is No, my spouse is I'm not sure

If you are not the insurance policy holder, please type the policy holder’s name and date of birth here:

Please select the counselor you would like to meet with.(required)

Madison Schultz, LPC (accepts insurance, telehealth and in-person) Kelsey Brown, PLPC (private pay only, telehealth only) Creative Counseling and Wellness (accepts insurance, telehealth and in-person) I do not have a preference.

Please use this space to ask any questions, let us know of any concerns, or tell us anything else you would like us to know about you!

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