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.

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A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
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:
Home 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).
Why are you asking for this?
(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?
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."
Why are you asking for this?
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)
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)
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)
What is art therapy?
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.