To become a new client, please fill out the form below. All new clients MUST fill out this form, in its entirety, to begin the intake process. If this form is not completely filled out, there may be a significant delay in starting services. Please begin by clicking next to the "First Name" field. 

If you are a private pay client, not using insurance, and DO NOT plan to use out-of-network benefits to receive reimbursement from your insurance company, please make sure you indicate that below so that you may be provided a "Good Faith Estimate" of the estimated cost of services. 




Do you consent to receiving emails?:
Are you a previous client of BFCW?:
Referral Source:
Service(s) being requested (Scroll)?:
Legal decision maker for minor under 12?:
Is DHS currently involved?:
DHS Case Contacts:
Is their a Guardian ad Litem (GAL)?:
Name and Contact Info for GAL:
Is there legal involvement?:
Is there current domestic violence?:
Recent substance abuse?:
Is this eating disorders related?:
Recent mental health hospitalization?:
Do you currently see another provider?:
LGBTQIA+ affirming provider?:
Christian/Faith Based Counseling?:
Specific provider you want to work with?:
Payment Type (Scroll):
Using Insurance?:
Insurance ID#:
Date of Birth:
Preferred location of service?:
Briefly, why are you seeking services?: