About
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Counseling
>
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Identity Expression and Esteem
Our Philosophy
Body Based Philosophy
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Scheduling Appointments/Intake
Scheduling Appointments
Counseling Individual Consultation Form
Counseling - Couple/Partner Consultation Form
Coaching/Hypnotherapy Session(s)
Intake & Assessments - Forms
Healthy Love for the Self and Others
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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 b
ook 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
*
Indicates required field
Please type the DATE and TIME of Appointment given on Schedulicity.
*
Step #2
Consultation
If you are submitting this form on behalf of someone else, please fill out the section marked "informant/guardian".
Today's Date
*
Client's #1 Legal Name
*
First
Last
Client #1 Mobile Number
*
Client Age
*
Client's #1 Preferred Name
*
First
Last
If your preferred name is different than your legal name.
Client #1 Email
*
Client Date of Birth
*
Informant/Guardian (if different from Client)
*
First
Last
Informant Phone Number
*
Informant Email
*
Relationship to Client
*
For example, spouse/partner or parent
Contact Referral Type
*
ITS Website Contact
Websearch
Psychology Today
Returning Client
Referred by a Client
Referred by Staff
Referred by another Clinician
Referred by an agency
Referred by court
Other
If you were referred please type person/agency name below or type "N/A" if not applicable.
*
If you were a past client, please type the name of your provider below. If not applicable type "N/A".
*
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.
Presenting Concern(s) & Desired Goals
*
Are any of the following dynamics causing conflict?
*
difficulty managing overwhelming feelings
worries that overwhelm your daily activities
relationships which lack trust or closeness
work disappointments or dissatisfaction
religion / spirituality conflicts
financial conflicts
dark, gloomy thoughts about the present or future
sometimes thoughts race or jumble or heart races or sweating
past trauma disturbances
counting, checking, or obsessing is necessary to feel safe
affection, intimacy, or sexual dissatisfaction conflicts
Our Approach and Your preferences
What you should know about our approach--it is different than other counseling models!
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.
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.
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.)
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.
Your Race/Ethnicity
*
Your Gender
*
Your Preferred Pronouns
*
Your Spirituality/Religion
*
Other:
*
What identity factors are important to client #2?
*
What identity factors are important to client #3?
*
Payment/Insurance
What is important about the identity of your therapist?
*
How strongly do you feel about your request for a particular type of therapist? Scale 1 to 10 (strongest) Please write 1 sentence about why it is important.
*
Are you open to try our recommendations for the identity and type of counselor/therapy you might need? * After your intake we make recommendations based on your clinical needs. (Please see 3c below)
*
Yes
No
Do you object to having more than one counselor in your sessions and/or intake? (see 3d below for more details)
*
Yes I object to having more than one person
No I can work with the team approach
Are you seeking services because you have work, legal, or housing concerns?
*
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
Select One
*
Uninsured - No Insurance / Self-Pay Out of Pocket
Uninsured / Sliding Fee Scale Needed**
Under-Insured - High Deductible Plan / Self-Pay Out of Pocket
Under Insured - High Deductible Insurance Plan [sliding fee scale needed]
Private Insurance [select a carrier below]
EAP (Employment Assistance Program) [select carrier below]
**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.)
Select One
*
Aetna (HMO/PPO)
Blue Cross/Blue Shield
Independence Blue Cross
Keystone Health Plan East (HMO/PPO)
Magellan
Highmark
Private Insurance We currently accept the following insurances: Aetna, Blue Cross/Blue Shield; Magellan, Highmark, Pennsylvania Independence Blue Cross and Blue Shield, Pennsylvania Keystone Health Plan (if Magellan is the managed care company for the Blue and Keystone Coverages), and many EAP programs such as Anthem, ACI, and Health Advocate.
Out of Network Benefit
*
Please type your insurance carrier and call member services to see if you have an out of network plan. See further instructions below.
Insured Member Name
*
Insured Member ID
*
Insured Date of Birth
*
Is Client #2 covered on Same Insurance Plan?
*
Yes
No
If no, type Client #2 Insurance Name & Member ID & Date of Birth
*
Is Client #3 covered on same Insurance Plan?
*
Yes
No
If no, type Client #3 Insurance Name, Member ID, and Date of Birth
*
Employee Assistance Programs
*
Anthem
ACI
(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.
Sundays
*
Thursdays
*
Mondays
*
Fridays
*
Tuesdays
*
Saturdays
*
Wednesdays
*
Have you completed your availability?
*
Yes
No
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).
Your preference virtual / in-person
*
I preferred virtual
I preferred in-person and am alright with possibly having to reschedule for a Thursday or Saturday when staff is in office.
I am flexible with either virtual or in-person.
Signature
Form was completed by:
*
Client
Client Representative/Family Member
ITS Staff
Spouse/Partner/Significant Other
Name of the person who completed the form
*
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 fe
w 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.
Submit
About
Our Services
Counseling
>
Couples & Pre-Marital
Body Based Interventions
Identity Expression and Esteem
Our Philosophy
Body Based Philosophy
Our Staff
Counselors (Psychotherapists)
>
Counseling Advisors
Coaching
Consultants
>
Consultants Advisors
Lifestyle Medicine Coaches
Business Operations
Scheduling Appointments/Intake
Scheduling Appointments
Counseling Individual Consultation Form
Counseling - Couple/Partner Consultation Form
Coaching/Hypnotherapy Session(s)
Intake & Assessments - Forms
Healthy Love for the Self and Others
Contact Us
Clinical Referrals
Staff Log-In