Therapy Consult Questionnaire | Care Beyond Campus

Thank you for taking this step with us. These questions help us learn more about your needs so we can connect you with the clinician best suited to support you. We'll review your responses and reach out within 48 business hours to confirm your intake appointment.

Legal First Name

Legal Last Name

If you go by a name that's different from your legal name, please share it here so we can address you correctly.

What college/university do you attend?

Please enter the address we should use as your primary residence for care and records below.

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Which best describes this address?

On-campus housing

Off-campus housing

Permanent/family home

Other

Email

Phone

Self-pay? You can skip the remaining questions and scroll down to the submit button to complete your form. Our out-of-pocket rate is $135 per session.

If you'll be using insurance to pay for sessions, please select the name of your carrier.

If the insurance company you have a plan with is not listed, we'd be happy to see you as a self-pay client for $135 per session.

Birthday

Month

Day

Year

Your date of birth helps us verify your insurance benefits accurately. This information is kept confidential and used only for coverage verification.

If you plan to use insurance for your sessions, please upload a clear photo of the front of your insurance card. This helps us verify your benefits before your consultation so we can confirm your co-pay and coverage details.

Please be sure to upload both sides of your insurance card so we can verify your insurance details in advance.

Please upload a clear photo of the back of your insurance card. This side often includes important contact and plan details that help us during the verification process.

Please be sure to upload both sides of your insurance card so we can verify your insurance details in advance.

Are you the primary subscriber on your insurance plan?

Yes

No

If your insurance is under a parent/guardian, spouse/partner, or another individual, please complete the information below. This helps us confirm coverage before your consultation and avoid delays.

Subscriber's First Name

Subscriber's Last Name

Subscriber's Gender

Subscriber's Date of Birth

Month

Day

Year

Subscriber's Relationship to You

Subscriber's Address

Subscriber's Phone

Subscriber's Employer

Our therapy model explores how early family patterns may be contributing to mental health symptoms (e.g. anxiety, depression), academic stress, and relationship challenges. Exploring family dynamics is a core part of our work. Which best describes you?

I understand this and am open to exploring family patterns during therapy.

I am seeking symptom-focused therapy only and do not want to explore family dynamics. (If this describes you, our practice is not the best fit)

Our process includes evidence-based assessments and structured intake, goal-setting, & treatment plan sessions before starting therapy. Are you comfortable with your care beginning in an organized structure that follows a clear step-by-step approach?

Yes.

I prefer a more informal approach to therapy. (If this describes you, our practice is not the best fit)

When you think about your current challenges, which feels most accurate?

I experience anxiety, depression, stress, or other mental health symptoms but have not considered how my family history may be connected.

I recognize that patterns from my family or upbringing may be affecting me.

I'm not sure, but I'm open to exploring possible connections.

With your academic and social experiences and the kind of work we do here in mind, what feels most important for us to know about why you're seeking therapy?

Over the past year, have you had thoughts of suicide or taken steps to harm yourself or end your life?

Yes

No

If you answer "yes," it does not affect your ability to receive care, it gives us the insight to plan your care safely.

If yes, please tell us a bit more about when that was, what was happening for you around that time, and how you're doing now.

Have you been discharged from a psychiatric hospital or inpatient program in the past 12 months?

Yes

No

If yes, please share the facility name and your approximate admission or program start date.

Which day(s) do you have the most flexibility to meet for your first session?

This helps us explore which of our available appointments might work best for you.

What time(s) of day would you prefer your first session be scheduled for?

Morning (7a-12p)

Afternoon (12-5p)

Evening (5-9p)

Based on the availability you shared, are there any dates or times you are unavailable to meet in the next two weeks?

Please share exact dates and consider exams, study sessions, travel, competitions, events, appointments, interviews, and other non-recurring commitments.

During academic breaks (fall, winter, spring, summer), what do you expect your therapy schedule to look like?

I plan to continue sessions during breaks.

I plan to pause therapy during breaks.

I'm unsure right now.

Note: Your therapist will check in with you closer to each break to confirm or adjust your plan.

If you're comfortable sharing, please let us know the specific person, office, or program that referred you.

Therapy Consultation Questionnaire