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

Sex at birth

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

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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

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

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Preferred clinician

Select a clinician from the list

No results found.

What is your preferred format for sessions?

Check all that apply. Note on Availability: We currently have limited in-person availability. Choosing only "In person in Fort Collins" may result in a longer wait time. Checking "Virtual" may allow us to match you with a provider sooner.

In person in Fort Collins Virtual Hybrid

To potentially shorten your wait time, are you open to an alternative format?

Note: Our current availability is highest for Virtual sessions.

Yes, I am open to Virtual sessions to start sooner. Yes, I am open to Hybrid sessions. No, I can only do my preferred format listed above.

Do you have any questions?

If you have any questions regarding services, waitlist process, therapy, resources, 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:

Waitlist placement is limited and not gaurenteed. This contact form is only to prescreen and approve/disapprove waitlist placement. I am agreeing to be emailed, texted, or called regarding waitlist placement. I understand that completion of this form does not indicate a therapeutic or waitlist agreement with The Rainbow Circles. If I do not hear from someone in 3 weeks time and I am still looking for a therapist I may complete this form again or follow up with therainbowcircles@gmail.com

Yes, I Agree

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.