New Client Screening | Restoration Family Counseling

Name *

Email Address *

Phone Number *

Date of Birth for Individual Seeking Counseling:

Insurance Provider:

Subscriber ID #:

Scheduling Availability / Flexibility:

Location Preference for Sessions:

Briefly, in 1-2 sentences, what brings you to seek counseling? If you are seeking family therapy, please include ages of family members:

COVID-19 Vaccination Status for all Eligible Household Members:

We have clinicians on our team who are immunocompromised and/or have family members in their home who are unable to be vaccinated. Your vaccination status will help us match you to an appropriate clinician and will NOT impact your ability to receive services, potentially in our office or virtually.

For minor clients, does your child have a parent that lives outside of your home? If so, please share custody information and if both parents consent to starting therapy: