Name of person filling out this form? *

Name of person filling out this form Phone Number? *

Name of person filling out this form email? *

In the following sections below, please answer each question as the person seeking treatment/recovery/support. If you are a parent and your child is over the age of 16, please allow them to answer the questions below, if they are willing. If you feel they will not give mature responses, feel free to complete the information below yourself. If your child is below 16 please answer the question below to the best of your knowledge.

Tell us about yourself

First Name of person seeking treatment? *

Last name of person seeking treatment? *

Insurance provider contact

Email of person seeking treatment? *

In what city do you live in? *

Age *

Insurance Provider - (For participating therapist referral ONLY)

Insurance provider contact

Insurance provider email - If applicable

Tell us about your history

Maritial Status *

How many kids do you have (Person seeking treatment)? *

What type of therapy/recovery are you seeking? *All professional therapy options below are performed by biblically based licensed ministers. This also includes our professional licensed mental health advocates as well. If you are looking for non-religious religious professional therapy be sure to let us know that information when we reach out to you as we have other options as well. *

Have you experienced any form of spiritual or non-spiritual counseling / therapy in the past? *

If you have experienced counseling / therapy in the past please describe your experience to the best of your ability.

Are you currently on any medications? *

If you are currently on medications, please tell us the name of each medication below? No need to tell us the reason for prescription.

Tell us about your problem area(s)

Tell us about any personal problem(s) you are experiencing or encountering that you are seeking therapy/treatment/support for: Check all that apply! *

Briefly, describe the moment you knew your problem area's became a concern, an addiction, or a serious issue? Try your best to describe the occasion and who all was involved as you answer this question. If you do not remember just state, "I do not know." *

Select all solutions you've attempted to deal with your problem area(s)? *

Were any of the treatment solutions you tried above effective, even for a short period of time?

How often are you encountering and/or experiencing these issues throughout the day? *

How often are you encountering and/or experiencing your problem area(s) throughout the week? *

Do you have an idea of what your triggers may be? Please describe the history and a theory you hold in regards to why you believe these are your triggers. *

When does your problem area normally occur? (Check all that applies) *

Where are you normally located when you experience and/or encounter your problem area(s)? *

To the best of your knowledge, what usually flows through your mind before, during and after you experience and/or encounter your problem area(s)? (Nothing is weird, everything you can think of helps with this process) *

Who is normally present when you encounter or experience your problem area(s)? (Check all that apply) *

To ensure your counselor properly addresses your situation, please tell us each individual that's aware you are experiencing these issues and problem area(s). Please use their first name (ONLY) and state your relationship with that individual. *

Let's get started

NOTICE:

Depending on the type of treatment and support you are seeking, these sessions can be intense, indepth with the goal of producing effective positive, results. We tell all of our patients to ensure you are comfortable with whom you choose to do any type of one-to-one counseling/therapy with as there arent any limits to the areas and topics your therapist may cover.

If you have a specific therepist / counselor that you'd like to inquire about or fullfill your sessions with please specify that in the next section. These session do cost, but varies depending on the therapist.

If you have insurance, only certain therepists within our network/program takes insurance. Please be sure to discover if your therapist takes insurance from your provider prior to begining your session(s) or be prepared to pay out of pocket costs.

Do you have a counselor or therapist in mind that you'd like to inquire about or begin your sessions with? If so, please select from the list below. *

If your insurance provider is out of our network what is a good price range you would consider for treatment/support? *Some of our advocates specify different rates than others. *Note all consultations and initial assessments are free. *

Please select your time zone *

Please check all box of possible availability for sessions? NOTE: Most of our counselors work during the business hours, but session times and locations are also at their discretion. *

How would you like for us to take your payment(s) prior to your sessions? *

Zelle Payment (Free - No Fee's)

Cash App Payment (Free - No Fee's)

Venmo Payment (Free - No Fee's)

Mail in cashier's check

Please send me a payment link for payment (Credit Card Processing fee's may apply)

I will add my card information below for payment (Credit Card Processing fee's may apply)

Card number

Expiration

Name on card

3-digit code (Normally on back of card)

*Please note that we process payments every friday morning at 8:00am prior to your next session.

Thank you for completing this form!

Someone from our team will be reaching out to you within 24 hours of submitting this form.

Thank you again,

The Motivating Youth Company

www.motivatingyouth.net

"it's your life, you should love it"