The Rainbow Circles | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

What are your pronouns?

How would you like to be contacted?

Select all that apply

Email Phone Call Text

Please note any other needs when contacting you

For example, let us know if we cannot leave voicemails, if we need to use different pronouns/name when leaving a message, etc.

Limited to 600 characters

Are you seeking therapy for a family, couple, or other committed relationship structure, including polyamorous families and relationships? If so, briefly describe the situation and the people who would be attending

Limited to 600 characters

Reason for care

What are your primary reasons and goals for coming to counseling?

Feel free to share details about what support you are looking for, modalities, previous mental health diagnoses, or any other relevant information. Be as brief or detailed as you feel comfortable with.

Limited to 600 characters

Are you looking for letter writing services?

Only select yes if you are needing a letter within 1 year.

No, I am not looking for letter writing services Yes Yes and I want to establish care

If yes, please explain as much as you can about your letter writing needs

Include when you need the letter by, insurance information, your other care providers, information regarding what you need the letter for, etc.

Limited to 600 characters

Please check all concerns you have personally had previously or are currently struggling with:

Problems with Sleeping Problems with Eating (increased appetite, decreased appetite, other, etc.) Racing Thoughts Struggling with Motivation Fear and/or Phobias Feeling Irritable Feeling Anxious, on edge, etc. Trouble Concentrating Losing Track of Time Memory Difficulties Not feeling real Easily Distracted Self-harming Wishing you were dead Thinking about suicide Attempting Suicide Being hospitalized for mental health concerns Isolating from others Fatigue/Low Energy Low Self-Esteem Urges to harm others Feeling Sad Often, Including Being Tearful or Crying Often Feeling Hopeless Feelings of Panic Substance Use (alcohol, recreational drugs, etc.) Obsessive or Compulsive Symptoms None of these

We have limited practitioners trained and available for specialized needs. To help us communicate accurate wait times and ensure we can meet your needs, please indicate below if you are seeking care that requires a specific specialized focus, advanced modality, or population expertise.

Examples include: EMDR, Play Therapy or Therapy for Children, Dissociative Identity Disorder (DID), etc.

Limited to 600 characters

Billing & Payment

Payment method

How do you plan to pay? Select each payment method you are willing to use.

Insurance Self-Pay Employee Assistance Program (EAP) I am interested in pro-bono or sliding scale payments I am not sure

Insurance details

What insurance do you have? (we will not charge your insurance until a session takes place)

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred Appointment Times

Please list what days and times you are available for appointments, and any scheduling limitations

Limited to 600 characters

Clinican Prefrences

Let us know if you have preferences for your clinician such as age, gender, ethnicity, race, or background. If you have a preferred TRC clinician, please list them here, staff members can be found at therainbowcircles.org/our-team. We match clients and therapists based on multiple factors, including clinical needs, provider expertise, availability, and client preferences. Sharing your preferences helps inform the matching process; however, we cannot guarantee that every preference will be met by a single provider.

Limited to 600 characters

Undesirable Clincican Prefrences

Let us know if you have any undesirable or exclusionary aspects about your preferred clinician, such as age, gender, ethnicity, race, background, experience, training, clinical modalities, etc,. Please also let us know if you do not wish to meet with a specific clinician, which can be found at therainbowcircles.org/our-team. We match clients and therapists based on multiple factors, including clinical needs, provider expertise, availability, and client preferences. Sharing your preferences helps inform the matching process; however, we cannot guarantee that every preference will be met by a single provider.

Limited to 600 characters

What is your preferred format for sessions?

TRC offers affirming, relationship-centered therapy both virtually and in person. Virtual therapy allows you to meet from your own space and expands your options for finding a provider who fits your needs. In-person and hybrid availability is more limited and may involve a longer wait. Check the option(s) that best reflects your preference

In person in Fort Collins Virtual Hybrid

Could virtual therapy also support your needs, if it is not your primary preference?

Note: Our current availability is highest for Virtual sessions.

Yes, please contact me about virtual options. Maybe—I would like to discuss whether virtual therapy could work for me. No, I need in-person or hybrid services.

Do you have any questions or anything the practitioner needs to know?

If you have any questions or anything the practitioner needs to know such as services, waitlist process, therapy, resources, what you'd like to focus on, insurance or payment questions, etc., please list them here.

Limited to 600 characters

How did you find our practice?

Check all that apply

The Rainbow Circles Instagram The Rainbow Circles Website Other Internet Platform or Social Media Referred by a therapist, counselor, psychiatrist, or physician Another Organization From a Friend or Family Member From a TRC Staff Member From a current or former client of The Rainbow Circles Word of Mouth Flyer/Public Posting An event with The Rainbow Circles

Completion of this contact form indicates your desire to be placed on a therapeutic waitlist and in no way starts or guarantees a therapeutic relationship or waitlist placement. By clicking "Yes, I Agree" on this agreement form you are acknowledging that you understand and agree to the following:

Wait list placement is limited and not guaranteed. This contact form only exists to gather brief info for a wait list placement. I am agreeing to be emailed, texted, or called regarding wait list placement. I understand that completion of this form does not indicate a therapeutic or wait list agreement with The Rainbow Circles. If I do not hear from someone in 6 weeks time and I am still looking for a therapist I may complete this form again or follow up with info@therainbowcircles.org

Yes, I Agree

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.