New Appointments: 718 313 HELP
(718 313 4357)
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New Appointments: 718 313 HELP (718 313 4357)
Schedule an Appointment
Thank you for choosing BCS Counseling Group.
Please fill in the form below to schedule an appointment. We will get back to you within 1 business day (Monday if you submit on the weekend).
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Full Name: (include parent name if appt is for child under 18)
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Phone
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Email
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Date of Birth
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Address
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Zip
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Gender (as shown on insurance documents)
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Are you a new client to BCS?
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INSURANCE DETAILS.
State N/A if no insurance
Insurance Provider:
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Insurance Member ID:
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Insured/subscribers name: (if not self / or state self)
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Relationship to insured: (if not self / or state self)
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Date of Birth of Insured: (if not self / or state self)
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ARE WE RIGHT FOR YOU:
Are you on psychiatric medication?
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If yes, what medications are you currently taking?
Will you be requesting medication?
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Do you have any history of drug or alcohol abuse?
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Have you been previously psychiatrically hospitalized?
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Are you presently suicidal?
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Do you think of hurting yourself?
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Appointments
When is the best time to call you in regard to making an appointment?
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Anytime
Reason for your Appointment?
(ie. Depression, Family conflict etc) This question is optional and confidential. It will help us connect you with the therapist most suited to your needs.
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