Client Inquiry Form - Advance Hope Mental Wellness

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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

Email *

Phone *

Date of Birth *

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Session Preferences:

Please select the service you are interested in. *

Coaching
Counseling
Either

Individual, Couple, or Family Sessions: Please select the type of sessions you are interested in. *

Individual
Couple
Family

Session Format: Please indicate your preferred session format. *

Telehealth sessions
In Person sessions
Either format is acceptable

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

Please select your insurance status *

I have insurance
Self-pay
I need financial assistance

Presenting Concern:

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

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

Depression
Anxiety
Stress
Trauma
Relationships
Grief and Loss
Self Esteem
Family Issues
Anger Management
Addiction
Other (please specify below)

Other Mental Health Issue/Concern:

Emergency Contact Information

Name *

First

Last

Phone *

How did you hear about Advance Hope Mental Wellness?

Acknowledge and Sign

By providing this information for the purpose of seeking coaching or counseling, you grant permission to be contacted by a representative of Advance Hope Mental Wellness regarding scheduling.

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

By submitting this form, you acknowledge that the information provided is accurate and complete to the best of your knowledge.

Thank you for choosing Advance Hope Mental Wellness. 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. *

Date / Time

Date

Time