Have you worked with Umbrella Collective before? *

Yes

No

Who is completing this form? *

For myself

For someone else

As a Family/Partnered

Legal Name *

Legal name of the person referred OR who is considered the "primary client"

First Name

Last Name

CHOSEN NAME

Chosen name of the person referred

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Please let us know your preferred way of being contacted

Email

Phone

Text

How do you plan to pay for therapy? (current available options listed below) *

If we do not accept your insurance we will provide a super bill for sessions you pay for at the full private rate (from $150). If you cannot afford the full private rate, you may ask your therapist for a sliding scale fee. Each therapist charges their own rates per experience and space on their caseload. We do not charge people on Medicaid any fee. Clients with Medicaid who do not show or late cancel two or more times may be asked to seek services elsewhere.

Private Pay (from $150)

Medicaid - RAE 6 or 7, Colorado Community Health Alliance

Medicaid - RAE 3 or 5, Colorado Access

What kind of therapy are you seeking today? *

Individual

Group

Individual & Group

If you've elected group therapy, which groups interest you the most?

Therapeutic groups provide opportunity to create powerful healing experiences for people. To begin in group, a therapist will outreach to you complete a 30-min group consultation.

Supporting Transgender Family and Friends (complete registration here - http://www.umbrellacollective.org/soffa-support)

Long-term Adult Online Therapy Group

Do you currently or have you struggled with drugs and/or alcohol in the past? *

Yes

No

Have you ever attempted suicide? *

If you are in a crisis please go to http://coloradocrisisservices.org/

Yes

No

Have you ever been hospitalized for mental health reasons? *

Yes

No

Check to add your email to subscribe to our listserv.

If you do not click the check box, you will not be added to our email listserv. You can come back to the website anytime to add yourself later.

Yes