Contact Guidepost Counseling Kids and Teen Inquiry Form Kids & Teen Inquiry Form 3 Parent/Guardian's Name * First Name Last Name Parent/Guardian's Email * Parent/Guardian's Phone Number * (###) ### #### Teen's Name * First Name Last Name Teen's Phone * We will not contact your teen, however our system requires this information for scheduling an appointment (###) ### #### What is your teen's age? * What is your teen's date of birth? * MM DD YYYY What is your teen's gender identity? * Please also include their preferred pronouns Does their gender identity differ from the gender assigned at birth? If so please explain * What is your primary reason for seeking support? * Describe in your own words your reason for seeking therapy * Are you willing to participate in your teens treatment? * Yes No Would you be willing to participate in a group setting to learn about the skills your teen is learning to better support them in their mental health journey? * Yes No What is your preferred meeting location? * In Person Telehealth What days are you available for an appointment? * Monday Tuesday Wednesday Thursday Friday For each day, what times are you available for an appointment? * What is your preferred billing tier? * Masters Level Clinician - $120 individual, $140 family Licensed Clinician - $150 individual, $180 family Supervisor/Specialist - $200 Support Group - $30 per week Therapy Group - $50 per week Do you need to use insurance for services? * *Please note, we are only in-network with a select few insurance companies. If you need to use insurance, you must provide the details of your plan below. We cannot guarantee coverage. You are responsible for all expenses incurred that are not covered by your insurance. If you are relying on insurance to pay for services, you must verify your benefits with out care coordinator before beginning services. Support groups are non-billable to insurance, we can only bill therapy services to any insurance plan. Yes No If you answered YES to the previous question, please complete the rest of the form. If you answered NO, you may submit now. Please enter the name & employer of the benefit subscriber Please enter the date of birth of the benefit subscriber MM DD YYYY Please select your insurance company Blue Shield Aetna Anthem Blue Cross United Healthcare Partnership Health Plan Cigna Other If you selected Other, please specify Please provide your subscriber ID How did you hear about us? * For the most accurate coverage information, please email a photo of the front & back of your insurance card to Billing@GuidepostTherapy.com Privacy Assurance for Our Clients At Guidepost Counseling, we are deeply committed to maintaining the confidentiality and privacy of all our website visitors. Rest assured that your personal information and browsing data are securely protected and will never be shared without your explicit consent. Disclaimer By providing my contact information, I acknowledge and give my explicit consent to be contacted via SMS and receive emails for various purposes, which may include marketing and promotional content. Message and data rates may apply. Message frequency may vary. Reply STOP to opt out. Refer to our Privacy Policy for more information. Thank you! We will reach out to schedule your free client match consultation call shortly. Adult Inquiry Form Adult Inquiry Form Name * First Name Last Name Email * Phone Number * (###) ### #### Preferred Date & Time * Do you need to use insurance for services? * *Please note, we are only in-network with a select few insurance companies. If you need to use insurance, you must provide the details of your plan below. We cannot guarantee coverage. You are responsible for all expenses incurred that are not covered by your insurance. If you are relying on insurance to pay for services, you must verify your benefits with out care coordinator before beginning services. Support groups are non-billable to insurance, we can only bill therapy services to any insurance plan. Yes No Please select your insurance company Blue Shield Aetna Anthem Blue Cross United Healthcare Partnership Health Plan Cigna Other Anything else you'd like to add? How did you hear about us? * Privacy Assurance for Our Clients At Guidepost Counseling, we are deeply committed to maintaining the confidentiality and privacy of all our website visitors. Rest assured that your personal information and browsing data are securely protected and will never be shared without your explicit consent. Disclaimer By providing my contact information, I acknowledge and give my explicit consent to be contacted via SMS and receive emails for various purposes, which may include marketing and promotional content. Message and data rates may apply. Message frequency may vary. Reply STOP to opt out. Refer to our Privacy Policy for more information. Thank you! We will reach out to schedule your free client match consultation call shortly.
