Queer Asterisk Client Screening Form

Hi there,

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.

* indicates a required field

If this is a therapy request for a minor 17 years old or younger, and you are completing this form for that minor, are you a legal guardian with medical decision-making power?

This process must be completed with the involvement of a legal guardian with medical decision-making power. Please close this page, and submit a new screening form with the involvement of a legal guardian with medical decision-making power.

Your Name:

First Name:

Last Name:

Your Gender Identity and Pronouns:

Your Date of Birth:

Your Age:

If you are between the ages of 12 and 17, are you looking to access counseling without parental involvement?

Please say more about why you are looking to access counseling without parental involvement:

If you are seeking counseling services for a minor under the age of 18, do they consent to their own treatment?

Please share some brief details about the circumstances around this:

Your Phone Number:

Home Address:

Address (1):

Address (2):

City:

State:

Zip:

Your Email Address:

IMPORTANT: For paperwork signature purposes, we require a personal email address for any minors 12-17 years old, in addition to the emails of any guardians involved. Please specify which email belongs to the 12-17 year old, and which email(s) belong to the guardian(s).

What is your government sex listed as:

Why are you asking for this?

Emergency Contact name:

(IMPORTANT: Please include the name and contact information for someone who is NOT you in the emergency contact field.)

Why are you asking for this?

Emergency Contact Phone Number:

Emergency Contact Email Address:

How did you hear about us?

Currently all of our counseling services are provided over telehealth. Are you open to Telehealth services?

Queer Asterisk offers therapy groups as a key component to treatment planning for some indivduals. We may have current therapy groups that are relevant to you. Please check here if you are particularly interested in our therapy groups.

Yes

Are you looking to use insurance to access counseling services?

Please provide the following information for the primary insured party (if you are a client seeking relational counseling, please answer these insurance questions using only the information of the person who is the primary insured party. If you are seeking family counseling to support a child under the age of 18, please use the information of the child).

IMPORTANT: We will verify your insurance benefits during your screening process, and you will receive a message from our billing team with your current benefits. Receiving this message DOES NOT guarantee we can use your insurance, since our intern counselors can only accept some forms of insurance. Our Client Care team will be in touch with you after insurance verification to support you in setting up a sliding scale if your specific insurance will not cover sessions with an intern.

By providing your insurance information in this way, you consent to us sharing your insurance information with our third-party billing service. This information will only be used by our Billing Team to verify your insurance benefits."

What is the legal name your insurance has you listed under (if different than the name listed above)?

Why are you asking for this?

Is the insurance subscriber different from the person who is seeking counseling? The insurance subscriber is the person who the insurance primarily belongs to.

Insurance Subscriber First Name:

Insurance Subscriber Last Name:

Insurance Subscriber Street Address

Insurance Subscriber City

Insurance Subscriber State

Insurance Subscriber Zip Code

Insurance Subscriber Date of Birth

Insurance Subscriber Relationship to Client

If you are looking to use insurance to access counseling, please upload a picture of the front of your insurance card AND a separate picture of the back of your insurance card below. (4MB max)

Front of Insurance Card

Back of Insurance Card

I don’t have an insurance card to take pictures of

Please list the name of your insurance provider, your member and group ID numbers (some insurances do not have group ID numbers), and the best phone number to reach your insurance provider by:

I have a second insurance to add

Yes No

If you are looking to use a SECOND insurance to access counseling, please upload a picture of the front of your insurance card AND a separate picture of the back of your insurance card below. (4MB max)

Front of Second Insurance Card

Back of Second Insurance Card

I don’t have an insurance card to take pictures of:

Please list the name of your insurance provider, your member and group ID numbers (some insurances do not have group ID numbers), and the best phone number to reach your insurance provider by:

Is the insurance subscriber for this second insurance different from the person who is seeking counseling? The 'insurance subscriber' is the person who the insurance primarily belongs to.

Second Insurance Subscriber First Name:

Second Insurance Subscriber Last Name:

Second Insurance Subscriber Street Address

Second Insurance Subscriber City

Second Insurance Subscriber State

Second Insurance Subscriber Zip Code

Second Insurance Subscriber Date of Birth

Second Insurance Subscriber Relationship to Client

I have a third insurance to add

Yes No

If you are looking to use a Third insurance to access counseling, please upload a picture of the front of your insurance card AND a separate picture of the back of your insurance card below. (4MB max)

Front of Third Insurance Card

Back of Third Insurance Card

I don’t have an insurance card to take pictures of:

Please list the name of your third insurance provider, your member and group ID numbers (some insurances do not have group ID numbers), and the best phone number to reach your insurance provider by:

Is the insurance subscriber for this third insurance different from the person who is seeking counseling? The 'insurance subscriber' is the person who the insurance primarily belongs to.

Third Insurance Subscriber First Name:

Third Insurance Subscriber Last Name:

Third Insurance Subscriber Street Address

Third Insurance Subscriber City

Third Insurance Subscriber State

Third Insurance Subscriber Zip Code

Third Insurance Subscriber Date of Birth

Third Insurance Subscriber Relationship to Client

Please list the insurances you plan to use in the order they are to be used in (which is primary, secondary, teritary). If you are just using one insurance, please type "N/A".

If you do not have insurance, or would like to opt out of insurance (not use your insurance for any reason), please click yes below to opt out and we will work with you for a self-pay agreement, including sliding scale options. If you are planning to use insurance, select “Does Not Apply”

Are you looking for a counselor with shared identities and experiences? Examples: identify as LGBTQ and want a LGBTQ counselor; identify as BIPOC, POC, or AAPI and want a counselor with those identities.

Please Say More:

Are you specifically seeking individual counseling or relational counseling (couples, family, polycule, friend, co-worker, etc)?

Please list the full names and email addresses of any parties who will be participating in relational counseling.

If one is available, would you like to work with an art therapist?

What is art therapy?

Do you have any preferences around your counselor’s style of counseling?

Please Say More:

Overall, how would you rate your mental health during the past 60-days?

Have you previously received a formal mental health diagnosis?

Is there anything that feels important for your counselor to know about these past diagnoses which you are comfortable sharing now?

Have you been hospitalized during the past six months for a mental health related concern?

Is there anything that feels important for your counselor to know about this, which you are comfortable sharing now?:

Do you have any unusual experiences, such as hearing voices that other people cannot hear?

Is there anything that feels important for your counselor to know about this experience, which you are comfortable sharing now?

Do you ever see things that other people cannot see?

Is there anything that feels important for your counselor to know about this experience, which you are comfortable sharing now?:

Does it feel like past trauma is still negatively affecting your life?

Is there anything you would like to share about HOW you are currently affected by past trauma?

What are the main things you want to work on in therapy?

What are some of your strengths/things that you really like about yourself?

What else would you like us to know that we did not ask about today?

Our Client Care team strives to respond within one week of receiving your intake form. You may reach us at info@queerasterisk.com if you don’t hear back within a week of submitting your inquiry.

The Client Care team will review the information you provided in this screening form, create a chart for you, process your session financing information, and connect you with a great-fitting counselor for an initial consultation.

You will receive an email connecting you with that counselor. If you and this counselor choose to continue beyond the initial consultation, your counselor will send you an invitation to set up a client portal. Once your client portal is set up, you will receive some paperwork in your portal for your review and signature before your first counseling session.

IMPORTANT: When we create your client portal, you will receive an email from us through a service called Valant. The email will direct you to complete the setup of your client portal (a quick process that only takes a few minutes). Please complete the setup of your client portal as soon as possible once you receive this email from Valant. This will allow you to smoothly transition into care at Queer Asterisk.

What is Valant?

We recommend that you double-check your demographic information and provide a credit card number in your client portal after setting it up.