Podio

First name *

Tell us the name you go by. This doesn't have to be your legal first name.

Last name *

What are your pronouns? *

Race/Ethnicity *

Date of birth *

(Use YYYY-MM-DD for date and HH:MM:SS for time)

Date

Email *

Phone *

Zip code *

Due to licensing requirements, you must currently reside somewhere in the State of Texas to receive our services.

Health Insurance Provider *

If you do not currently have a health insurance provider, please put "none." If you are unsure about your current health insurance status, please put "unsure." Our individual services are designed primarily for those who are uninsured and have no other financial means. If there is a reasonable hardship preventing you from using insurance, please summarize it in this box as well.

I could pay for weekly counseling if it was $30 - $60 per session *

Please note Out Youth offers individual counseling for $10 per session in most cases, or we can offer no-cost counseling for those who qualify. Our individual services are designed primarily for those who are uninsured and have no other financial means. However, during the screening process, we are happy to meet with those insured and with financial means to discuss referrals to LGBTQIA+ affirming therapists.

Yes

No

Unsure

What type of counseling are you interested in? *

What days and times are you available for a counseling screening?

Screenings are usually over the phone or via Zoom. They typically last 30-45 minutes

Who referred you (if any)?

Have you participated in individual counseling at Out Youth before? *

Please only indicate "yes" if you have been in INDIVIDUAL services. If you have only participated in groups or short term case management, please answer "no". If you are unsure, answer "no".

If yes, indicate the name of previous counselor AND the month and year of your last session at Out Youth

Presenting concerns

This question is optional. Please select any that you may be struggling with or have a history of struggling with. Please keep in mind this list is general.

Additional information:

This question is optional. Please explain any of your selections above further and only to your comfort. As a reminder, this form is confidential but if we have any reason to believe yourself or another are in immediate danger, we may have to break confidentiality to keep you or others safe. If you are experiencing a mental health emergency, please discontinue this form and call 911.

What days and times are you available for a weekly counseling appointment?

If you are filling out this request for someone else, please indicate your name and your relation to them

Request a Counseling Screening