Equest Equine Counseling Interest Form

Contact Information

Full Name

Date of Birth

Phone

Preferred Method of Contact

PhoneEmailText Message

Veteran Status

Are you a veteran?

YesNo

Are you a spouse or dependent of a veteran?

YesNo

Referral Information

How did you hear about us?

PhysicanCurrent/Former ClientVeteran OrganizationEquestWebsiteSocial MediaGoogle SearchFriend/FamilyOther

Counseling Services Requested

What services are you interested in?

Individual CounselingCouples CounselingFamily CounselingOther

Reason for Seeking Counseling: Briefly describe what brings you to counseling at this time ( short answer)

Diagnosis Information

Have you ever been diagnosed with a mental health condition?

YesNo Unsure

If yes, please list any diagnoses you are aware of:

Counseling Experience

Have you previously participated in counseling or therapy

YesNo

Are you currently receiving counseling services elsewhere?

YesNo

Are you currently taking psychiatric medications?

YesNo

Scheduling Preferences

Preferred Days (check all that apply)

MondayTuesdayWednesdayThursdayFriday

Preferred Times

Morning (8am-12pm)Afternoon (12pm - 5pm)

Preferred Start Date:

All counseling services are private pay. We do not accept or bill insurance; however, we can provide a superbill for possible out-of-network reimbursement. Limited scholarship opportunities may be available for those who meet eligibility requirements and based on available funding.

If you are experiencing a mental health emergency or are in immediate danger, call 911 or 988, or go to your nearest emergency room.

Additional Information

Is there anything else you would like us to know before we contact you? (optional short answer)

Consent

I understand that submitting this form does not establish a counseling relationship

Once an interest form has been submitted, a copy of the completed form will be emailed to you, and a member of the Equest counseling team will contact you.

Contact Information