Good Grief Counseling | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What are your preferred pronouns?

Administrative

How did you hear about Good Grief Counseling?

Enter how you were referred to our services

Word of Mouth Internet Search (such as Google) Psychology Today Profile AI tool (such as ChatGPT, Gemini, etc)

Billing & Payment

Insurance details

You can type in your insurance provider and member/group numbers here, or just upload pictures of your card below, instead.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Are you interested in discussing our Financial Sustainability (Sliding Scale Fee) Policy?

If finances are an obstacle to your ability to receive services, we have a policy in place that may allow us to help.

Yes Not at this time

Reason for care

What is happening in your life right now that is motivating you to seek support?

Limited to 600 characters

What are some of your strengths, interests, or passions that keep you grounded?

This could be a hobby, a pet, a skill, or a personal value - anything you want to share about what makes you who you are.

Limited to 600 characters

What would you like to feel different in your life a few months from now?

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.