New Client Information Form

This form will help us know which of our therapists would be best to call you back to discuss how to start counseling here at JFA.

It’s OK if you don’t want to answer all of these questions now. But the more you tell us in this form, the easier it can be to get you the help you need or send you in a better direction. The fields with a red asterisk are required.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Email *

Phone *

What is your age or age of client?

What would you like help with today?

Do you have a preference for the gender of your therapist?

• Male
• Female
• No Preference

What services are you interested in?

• Individual Therapy
• Group Therapy
• Couples Therapy
• Family Therapy
• A Drug and Alcohol Evaluation

Do you think you want to stop drinking or using substances or other compulsive behaviors completely? It’s OK if you don’t know or are unsure.

• Yes I want to stop.
• No I am not ready to stop.
• I’m not sure if I want to or am ready to stop.

Would you like to be seen in an office? Or virtual? Or both?

• Office
• Virtual
• Combination of both office visits and virtual.

If you want to be seen in an office for part or all of your therapy, which office location do you prefer?

• Bala Cynwyd Office
• Center City Philadelphia Office

$220 do you

We do not take insurance directly (we don’t sign contracts with insurance companies), but some of our clinicians/associates can give “super bills” which your insurance company can use to reimburse you for fees if they/you have out-of network reimbursement benefits. Do you absolutely need reimbursement from your insurance company, or can you afford out-of-pocket fees in the range of $220 to $120 per session?

• Yes, I need reimbursement from my insurance company.
• I don’t need reimbursement and can afford the fees listed.

Will family or someone else be helping you with fees?

• Yes, they will help me.
• No, I’ll handle costs myself.

Do you have any other questions?

Who referred you to our practice? (If you feel comfortable sharing.)

We try to get back to folks within 24 to 48 hours. If you don’t hear from us within that timeframe, please call or text 215-356-8061.

Submit

This information will not be shared with anyone outside of JFA without your permission at any time.