Inner North Counseling LLC

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

What brings you to therapy at this time?

Briefly share what you’ve been experiencing, any concerns or symptoms, and how long this has been going on.

What are your goals for therapy?

What would you like to feel different, understand better, or work toward?

Are there any immediate stressors or concerns you’re hoping to focus on right now?

i.e. recent changes, relationship stress, work or school issues, anxiety, mood concerns, health stressors, or anything else feeling urgent.

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Insurance carrier (e.g., Highmark, Aetna, UPMC), plan name if known, and state the plan is based in.

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend (Saturday)

Is there anything helpful for me to know before reaching out?

Limited to 600 characters

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.