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Form for Prospective Behavioral Health Clients (PLEASE NOTE THIS PROGRAM IS CURRENTLY WAITLISTED)

Affirmations offers LGBTQ+ affirming mental health services in a safe and welcoming environment for individuals, couples, non-monogamous relationships, and families, including those from all cultures, ethnicities, sexual orientations, and gender identities.

Our mental health services are provided by licensed professionals, or by student interns supervised by licensed professionals. Sliding fee scale and some insurance accepted. 

Completion of this form does not guarantee eligibility or admission to the program. However, if you are not admitted to the program we will attempt to refer you to other resources.


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Pronouns (what you would like us to use when referring to you, e.g. “she would like a callback,” “they would like a callback,” “he would like a callback,” etc.) *


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Please upload a photo of your ID.
Affirmations is working to expand the insurances we are authorized to bill. You are not required to have insurance to receive therapy. Sliding fee scale payment option available.

If you have insurance, please list the specific type above.

If you have insurance, please upload a photo of your Insurance Card above.
If requesting both individual therapy and therapy as a couple/relationship/family, you will see two separate therapists.
Please use the space below to select any providers you would be comfortable working with:

Please use this space above as a short answer.

Please use this space above as a short answer.

Please use this space above as a short answer.

Please use this space above as a short answer.