QA Client Screening Form
Thank you so much for your interest in working with one of our counselors at Queer Asterisk. We are so excited to get to know you better! This confidential screening form will help us understand what you’re going through, the services you are looking for, and help us match you with a counselor that can best meet your needs.
We know some of these questions might be sensitive in nature. In order to best serve you and meet your needs, we have determined that these questions are necessary in connecting you to the best services. You can decline to answer any questions and wait to discuss these concerns with a counselor. All information on this form will also be shared with the counselor that you get initial matched with.
Please be aware that the counselor reviewing this form is a mandatory reporter. As such, they are required to report: immediate danger to your own life and/or others; any current child and/or elder abuse, neglect, and harm; any past child abuse where the abuser is still in a position of trust with children today; if you are under the age of 18, we need to report any current suicidal ideation to your parents/guardians/caregivers. Thanks so much for taking the time to fill out this form.
IMPORTANT: If you are seeking therapy for a minor (under 17 years old), please make sure to have them fill out the screening form, or have them present while you fill it out on their behalf. For paperwork signature purposes, we require a personal email address for any minors 12-17 years old, in addition to the emails of any legal guardians involved. If you are seeking couples or relational counseling, please have the party who is the primary insurance holder fill out the screening form.
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