Individual Consultation Form

    Consultation is the beginning process to get to know you, your concerns, and gather information that will help us to serve you best.  In order to fill out this form, you will need to book the appointment first and have the DATE AND TIME ready to type below! Request an appointment using Schedulicity, please read instructions how on our scheduling appointment page. (click here)
    Step #1 Appointment Scheduling
    Step #2  Consultation
    If you are submitting this form on behalf of someone else, please fill out the section marked "informant/guardian".
    Please tell us why you are seeking treatment at this time.  Please also tell us if you are experiencing mental or physical health symptoms that impact your daily living.

    Our Approach and Your preferences
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    What you should know about our approach--it is different than other counseling models!

    1. Intake counselors are whomever is on staff that day of intake, so please be prepared to meet someone on our team who will take good care of you for intake but who may not be your counselor unless you request so, and they have availability and skill to work with your case. 
    2. When Intake counselors complete the intake, there is sometimes a waiting period between completion of intake and client assignment of primary counselor and team (if applicable). If you have any concerns please contact the numbers for support below, if more than 2 weeks past between the intake and your assignment for sessions/team.
    3. Because we use a team approach, (see our staff philosophy for more details) it is possible that your intake session(s) will be with 2 team members; however only one will be conducting the intake process and the other will be taking notes about your preference to inform the selection of your counseling team. Sometimes senior clinicians, specialty practitioners, or coaches will need to witness regularly schedule sessions to be sure you reach your goals.  (If you strongly object to a team approach we might not be the right provider for you; we are willing to consider your request for a sole practitioner; however we will discuss the pro and cons of such a model with you.  You must however be open to a discussion about which is best--a team or sole practitioner approach--and be willing/able to evaluate the options.)
    4. Because we care about our customer service approach we sometimes monitor sessions either in-person or via video/audio recording.  You will never be recorded without your knowledge and consent however, and you have the right to consent to a recording and then ask for the recording to be stopped at any time for any reason.  You also have the right to deny being recorded in any form.

    ​Please tell us what is important to your identity or desired experience that might help us serve you better. Please tell us if any of the following identity factors are important to your experience. 

    Payment/Insurance
    Please read the options on our scheduling appointment page, which discuss payment types.  Then select the type of payment which fits your needs and ability.

    Payment Types
    ​**For clients needing sliding fee scale agreements, approval considerations:
    1) income driven - based on your salary you should be prepared to pay 7% - 15% of your income for your wellness.
    2) we give you a rate that is depended upon the frequency of care needed.  If you do not keep the frequency of sessions as agreed, your fee reverts to our regular session rates.
    3) we ask for a deposit, one payment ahead of the next session, or scheduled automatic payment plan (withdrawn from you banking institution/credit card on file).
    4) we reserve the right to approve, discontinue, or disapprove a payment plan request at any time; however we do our best to make our services affordable.

    Private Insurances / In-Network Plans

    (Sorry we do not take state paid plans such as Medicaid or Medicare - please see Scheduling Appointment for explanation.)
    (To check if we are in-network with your plan or if you have an out-of-network benefit,
    your customer services number on the back of your insurance card might ask
    ​for our NPI which is 158-805-6212, Inspired Therapeutic Solutions.)

    Availability

    Please tell us your availability by giving us times you're available each day for regularly scheduled sessions.

    Virtual or In-Person Sessions

    Do you have a preference for an in-person or virtual intake session(s)?  (We have limited in-person sessions available during COVID-19).

    ​Signature

    Consultation / Intake Process Steps

    Step #1  Appointment Setting
    Congratulations! You finished Step #1!
    Step #2  Consultation
    Congratulations!  Once you hit Submit below you finished Step #2!
    Step #3 Intake Preparation
    3a) Please go to our intake forms page (click here) and fill out the intake forms if you have already booked an appointment, or if you have been contacted by our staff with an appointment date. 
    3b) If you will to fill out the forms ahead of  time you may, just send completed forms to its.well.appointments@gmail.com.  YOU MUST FILL OUT THE INTAKE FORMS BEFORE 1ST SESSION. 

    ​​**Please contact us at 267-368-6630 or send a text to 215-833-5467 to ask for support or help. (We are only in office Thursdays and Saturdays during COVID-19 crisis so it might take a few days to respond.)
    Step #4 Confirmation
    A confirmation call and/or text will be sent to your phone or email to schedule or confirm your scheduled appointment.  If you do not receive any information to confirm your appointment by the day before your appointment, please call or text our business operations and compliance manager at 678-459-4678.