Client Inquiry Form - Advance Hope Mental Wellness

Start here for the fastest way to an appointment!

Thank you for considering Advance Hope Mental Wellness for your coaching and counseling needs. We're here to support you every step of the way. Please fill out the form below to be contacted by our Intake Coordinator.

Your Details:

Name

First

Last

Date of Birth

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Session Preferences:

SESSIONS: Please select the type of session you are interested in.

Individual
Couple
Minor

Do you consider spirituality or faith an important aspect of your life?

Yes, Christian faith important to me
I have a different faith belief that is important to me
I'm open to discussing my spirituality and faith
Spirituality not important to me

Session Format: Please indicate your preferred session format. (copy)

Telehealth sessions
In Person sessions
No Preference

Please select your method of payment

Self-pay
Insurance
Medicaid

Have you been referred by someone?

Presenting Concern:

Please describe the main issue or concern you'd like to address. (Briefly share the reason for seeking support.)

Common Mental Health Issues/Concerns: Please check any that apply.

Other Mental Health Issue/Concern:

How did you hear about Advance Hope Mental Wellness?

Is there anything else that would be helpful for us to know?

Contact Us

If you have any questions or need further assistance, please do not hesitate to contact us. | intake@advancehope.org | 406.201.1616

We genuinely appreciate your trust in us as we embark on this journey toward improving your mental wellbeing. Our dedicated Intake Coordinator will work closely with you to ensure a smooth and seamless experience. After carefully reviewing the information you provide, they will reach out to you within 48 hours to discuss the next steps and discuss the best coach or counselor for you. Our goal is to make sure your journey with us is comfortable and as worry-free as possible. Please type your first and last name below.