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. Applicants under 18 must have a legal guardian’s signature.
INSURANCE Abide Network sessions are typically not covered by insurance. If your provider is licensed in your state, you may request a superbill for potential reimbursement, otherwise assume you will be paying out of pocket.
Are you over 18 years of age?*
Personal Information About the individual receiving services
List any children and their ages
Financial Information Our certified coaches, trained by Dr. Jennifer Schwirzer, offer empathic listening and emotional support sessions for $25-$60. Our professional counselors, also trained by Dr. Schwirzer, hold graduate degrees, certifications, or licenses, with fees ranging from $60-$150. Intake Supervisor Jeanine Goodwin, RMFT, will match you with the best fit.
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 You may request a different coach at any time by reaching out to the Intake Supervisor. If you have no preference, keep "Choose for me" selected. Our coordinator will ensure you’re matched with the best fit.
Click here to browse available coaches.
Do you prefer male, female, or either?
Briefly describe what brought you to seek help, including current symptoms, interpersonal challenges, or other relevant details.
How did you hear about Abide Network?
Sign & Submit Terms and Conditions Abide Network coaches reserve the right to refer clients with issues outside the scope of our practice to other providers. Continuing or discontinuing services will depend on the situation.
Coaching sessions are confidential unless the client permits sharing or discloses 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?
