Abide Network Intake Form Fill out this form to be paired with one of our coaches.
Average time is 15–30 mins. Response time is 2-5 days.
Terms of Service LIABILITY Abide Network is a referral service. As such it does not establish a counselor/client relationship with persons seeking referrals. Neither is Abide responsible for, nor have oversight of, the relationship between the coach and the client.
INSURANCE Sessions through Abide Network are not generally covered by insurance. If your provider is licensed in your state, you are free to ask them for a superbill, which your insurance may reimburse. But it is best to assume you will pay fee-for-service.
Are you over 18 years of age?*
Are you filling out this form for yourself or someone else?*
Personal Information About the individual receiving services
List any children and their ages
Financial Information Our certified coaches have been trained by Dr. Jennifer Schwirzer in empathic listening, emotional support, and basic principles and techniques of mental and relational health. Their sessions range in price from $25-$60. Our professional counselors, whom Dr. Schwirzer has also trained, have earned graduate degrees, national certifications, and/or state licenses. They range in price from $60-$150. Our intake supervisor, Jeanine Goodwin, RMFT, can help place you with the person best suited to your needs.
How would you like to begin your journey towards improving your mental health?*
Pick which option best describes your situation:
List any additional details about you financial situation
Denominational Preference
Is faith an important part of your life? Is faith an important part of your life?
List all important past injuries or handicaps
List any current medical conditions
List all important past mental health problems you’ve experienced
Do you have a history of self-harm or suicide attempts? If so, please explain
Do you currently suffer with any psychotic episodes? If so, please explain
Do you have any current mental health diagnoses? If so, please explain
List any current providers you have, including address and phone
List any medications you’re currently taking, along with the dosage, how often you take them, and the condition they are for
Have you ever used drugs for purposes other than medical? If yes, explain
Use this space to give more details about your history.
Prior Treatment Previous mental health (MH) and substance abuse (SA) treatment: Please list most recent first.
Date, provider, level of care, duration, condition (MH/SA), outcome.
Family/Environmental List any history of mental health or substance abuse diagnoses in your family that you are aware of, using specific labels such as “alcoholism” or “depression.”
Mother/Father/Spouse or SO/Child/Other
Did you ever experience any emotional/physical or sexual abuse as a child?
Is there anything else significant about your childhood that you feel would be helpful to mention at this time?
Provider Preferences Please note that, at any point, you may make a request to the Intake Supervisor if you'd like to try coaching with a different coach. Leave blank if you have no preference. Our coordinator will make sure to match you with the most optimal one.
Browse available coaches by clicking here.
Which Abide counselor or coach do you prefer, if any?
Are you flexible if that person isn’t available?
Do you prefer male, female, or either?
Please provide a summary of what has led you to seek help at this time. What symptoms are you currently experiencing? Are there any interpersonal challenges you’d like to address? Share any additional info that you feel is relevant to your situation.
How did you hear about Abide Network?
Sign & Submit Terms and Conditions Abide Network coaches and counselors reserve the right to refer clients elsewhere should they display acute mental health problems, suicidality, current substance abuse, and complex legal issues. The coach or counselor may continue or discontinue coaching the client. This is subject to circumstances pertaining to each situation.
Everything discussed in the coaching sessions will be between only the coach and the client, unless the client gives permission to share information to specific individuals, or the client reveals information that indicates a threat of harm to self or others, as required by professional ethical standards.
Would you like to contribute to expanding mental health outreach and support?
