*Session Details (Check all that apply)

Individual Therapy ONLY: ADULT
Individual Therapy ONLY: MINOR
Family Therapy (not covered by most insurances)
Couples Therapy (not covered by most insurances)

Note: If this is for a MINOR, and parents are legally separated or divorced, please email a copy of the Custody Agreement to michelle@intentionalwellnesswv.com.

If this is for COUPLES, please indicate that you want "Couples Sessions." We will register you both together to streamline your paperwork. COUPLES COUNSELING IS NOT COVERED BY MOST INSURANCES.

Telehealth ONLY
In-Person ONLY
BLENDED: Telehealth, InPerson

Morning
Afternoon
Evenings
First Available/ No Preference

Please note: Evening appointments are VERY limited. Waitlists are likely. We do have some Saturday availability.

*Address (As Listed on Insurance)

*Birthday (MONTH/ date/year) *Accepting ages 6 and older*

MaleFemale

*Relationship Status

SingleMarriedIn a relationshipWidowedSeparatedDivorced

*Self-Pay, Insurance, or Division of Rehabilitation Services Collaborative

Self-PayInsuranceDeaf and Hard of Hearing Collaborative with the Department of Rehabilitation Services

*Primary Insurance Policy Holder Date of Birth (Spouse/Parent/etc...)

*Upload your Insurance Card:

Front:

Back:

*Are you currently suicidal?

No, I have never had suicidal thoughtsNo, I have had suicidal thoughts in the past, but I am stable today.Yes, I have passive thoughts but have good resources in placeI have attempted suicide in the past, but am stable todayYes, I am really struggling. Please call *988 or go to the nearest ER if you feel unsafe.

*I am a previous client of Intentional Wellness and Consulting.

YESNO