CHILD: New Client Request Form

Please complete the below form and our staff will reach out to you soon. We look forward to meeting you!

IF YOU ARE IN CRISIS, PLEASE CONTACT ANNE ARUNDEL CRISIS RESPONSE AT 410-768-5522.

STAFF ONLY: Check option below ONLY if you are Turning Stone Staff....

No, I'm a Client

STAFF MEMBER

Client Request Came in via... *

How did you hear about us? *

Who may we thank for referring you?

Do you require any special accommodations or assistance? *

No, I do not require any special accommodations/assistance during sessions or the intake process.

I will require assistance during sessions only.

I will require assistance in completing my intake forms, and possibly during sessions.

Yes, I need assistance with this Request Form and am unable to continue. Please contact me at the email or phone number provided below.

PARENT/GUARDIAN First Name *

PARENT/GUARDIAN Last Name *

PARENT/GUARDIAN Phone # *

PARENT/GUARDIAN Email *

What is your preferred contact method to discuss scheduling? *

Phone (Ok to leave a voice message)

Phone (DO NOT leave a voicemail)

Is there another parent/guardian NOT LIVING WITH YOU who shares legal custody of the minor/dependent client? *

Additional Parent FULL Name:

Additional Parent Phone #:

Additional Parent Email:

Child's FIRST & LAST Name *

Child's Date of Birth *

Child's Gender Identity *

Child's Preferred Pronouns

Please select the PRIMARY reason for seeking therapy: *

Select additional reasons for seeking therapy below:

Please provide some additional information about your REASONS & GOALS for therapy, which will help us determine the best match for you.

Are you willing to see a therapist who does NOT accept your insurance plan, or would you be willing to see a PRE-LICENSED counselor? *

Yes

Maybe, let's discuss options

Primary Insurance Provider *

Would you like to provide additional insurance details at this time? *

Yes

Front of Insurance Card

Back of Insurance Card

Primary Insurance Subscriber FULL NAME & Date of Birth

Appointment Preferences

Would you be open to doing virtual (telehealth) sessions? *

Yes, telehealth is ok.

Yes, but I'd prefer my first 1 or 2 sessions in-person if possible.

YES, I ONLY want virtual sessions.

NO, I ONLY want in-person sessions.

Do you have any specific Turning Stone therapists in mind as being a good fit?

For each weekday below, please select ALL TIMES you can be available for WEEKLY RECURRING SESSIONS.

(Please be advised that appointments at 3pm or later are in high demand, and we are not currently offering weekend sessions. )

MONDAYS

TUESDAYS

WEDNESDAYS

THURSDAY

FRIDAYS

We will call you to learn more in order to match you with the best therapist & discuss potential openings. Is there anything else you'd like us to know about you or your schedule availability?

Would you be interested in any of the following communications from Turning Stone Counseling? (Select all that apply)

Click ‘Submit’ below….

Please allow 24-48 business hours for response.