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Counseling Intake Form

Affirmations offers LGBTQ+ affirming Counseling in a safe and welcoming environment for individuals & couples age 18+ from all cultures, ethnicities, sexual orientations, and gender identities. Sliding fee scale and some insurance accepted. 

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First Name
Last Name

Please list the name you wish to be referred to as, if different from name listed above.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Please upload a photo of your ID.
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Affirmations is authorized to bill some insurances. We accept Blue Cross PPO and Traditional. You are not required to have insurance to receive therapy. Sliding fee scale payment option available.

If you have Blue Cross PPO or Traditional, please upload a photo of your Insurance Card.
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If requesting both individuals and couples therapy, you will see two separate therapists.
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Please use this space above as a short answer.
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