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Therapy Interest
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Client Interest
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*
" indicates required fields
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First Name
*
First
Last Name
*
Last
Date of Birth
*
MM slash DD slash YYYY
Month / Day / Year
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Who are you interested in connecting with?
*
A Therapist / Counselor / Mental Health Practitioner
A Psychiatric Nurse Practitioner
An Executive/Leadership Coach
Select which type of wellness provider you would like to see.
Have you had any experience with a mental health clinician? (i.e., a therapist or counselor)
Yes
No
Have you had any experience with an executive or leadership coach?
Yes
No
What career stage are you? (Select all that apply)
*
Early-Career (<10 years)
Mid-Career (10> years)
Late-Career (20> years)
Silver Skills (Post Retirement / Second Career)
Select what you'd like your coach to specialize in (Select up to 2)
*
Business
Career Pivot
Executive
Financial
Health & Wellness
Leadership
Life Transitions
What is your preferred coaching format? (Select all that apply)
*
Individual
Small Group (<10 people)
Small Teams (<20)
Large Teams (>20)
How would you describe your preferred flow of interaction during a coaching session? (Select all that apply)
*
I do most of the talking & my coach is an active / nonjudemental listener
My coach jumps in and challenges me when appropriate
My coach teaches me new skills / tools
My coach is more of a motivator
My coach integrates art / movement in sessions
I prefer to meet with my coach… (Select all that apply)
*
Before 9AM
Daytime Hours
After 5PM
Weekends
I prefer a coach of the following gender…
*
Female
Male
No preference
Non-binary/non-conforming
Transgender
Are you struggling as an individual or a couple/family?
Individual
Couple & Family
How did you learn about BLK Haven?
*
BLK Haven Website
Clinician (Counselor/Psychiatrist/Therapist)
BLK Haven Coach
Facebook
Google
Instagram
Word of Mouth (Friend/Family/Colleague)
YouTube
Were you referred by a BLK Haven Clinician or Coach?
*
If yes, please provide their first and last name. If no, enter N/A.
How will you pay for services with BLK Haven?
*
Insurance (Please, upload an image of the front and back of your insurance card. Missing this step will delay your enrollment process)
Cash-pay
Insurance ID (N/A if cash-pay)
*
Please, upload a front image of your insurance card.
*
Accepted file types: jpg, png, pdf, tif, gif, heic, Max. file size: 3 MB.
Please, upload a back image of your insurance card.
*
Accepted file types: jpg, png, pdf, tif, gif, heic, Max. file size: 3 MB.
Interested in being a private client?
*
Yes
No
Select ‘yes’ if you are interested in obtaining care from a clinician or coach highly trained in working with high profile clients.
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