FaithFULL Homestead Christian Counseling PLLC

FaithFULL Homestead Christian Counseling PLLC Send Message

Who would be receiving care?

My partner and me

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State

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Reason for care

What is the reason for seeking care?

Anxiety Depression Grief Relationship Issues Parenting Issues Hopelessness Powerlessness Anger Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

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Billing & Payment

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Insurance details

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Insurance card upload

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Client Preferences

Preferred appointment times

Morning (9:00am - 12:00pm) Afternoon (1:00pm - 4:00pm) Evenings are unavailable Weekends are unavailable

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.