Request for Services

Please complete this confidential form completely and accurately so that we can serve you in a timely fashion. Thank you!

Client Name

Email Address (Parent or Gaurdian email, if minor)

Date of Birth

Client Sex:

Do you plan on using insurance?

Yes

Unsure

Are you a college student? If yes, which college do you attend?

Parent/Guardian Name, if minor

Phone Number

Parent/Gaurdian DOB, if minor

Client Age

Are you planning to use Employment Assistance Program (EAP)?

Yes

Will you be physically bein the state of VA during the time you will be receiving services?

Yes

Member ID #

Please provide days/times that you are available. Monday-Friday 9am-8pm (Be as specific as possible: Mondays 12-3; Tues/Thurs 9-10:30, etc.)

Please provide a brief description as to why you are coming to counseling

Have you seen anouther counselor in the past 12 months?

Yes

Have you ever been seen by a counselor at Freedom Support Services?

Yes

Have you been screened for and/or admitted to a pyschiatric facility within the last 12 months?

Yes

If there are no openings available, would you like to be added to our waiting list?

Yes

Do you have a preference for the gender of your counselor?

Yes

If yes, what is your preference?

Male

Female

Do you have a preference for the race/ethnicity of your counselor?

Yes

If yes, what is your preference?

Providers

There are currently six providers in our office. Please check ALL of the providers that you are willing to see. You can learn more about all providers by clicking the links below:

Shaterra Walker, Resident in Counseling

Amanda Rigney, Licensed Professional Counselor

Nijera Jones, Licensed Professional Counselor

Chandra Shorter, Licensed Professional Counselor

Hannah Einstein, Licensed Professional Counselor

Genevieve Drews, Resident in Counseling

Tameesha Curry, Counseling Intern*

Jessie McGlothlin, Licensed Professional Counselor

Carissa Fraser, Counseling Intern*

Thank you for your interest in our services. We have a high volume of requests and strive to respond to all requests for services within 2 business day. If you do not hear back from us, please send a courtesy email to contact@myfreedomss.com. Thank you!

Request for Services

Please complete this confidential form completely and accurately so that we can serve you in a timely fashion. Thank you!

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