In 2019, Triangle Community Center (TCC)  launched counseling services for the LGBTQ community. Supervised by an LMFT (Licensed Marriage & Family Therapist), MFT students provide comprehensive counseling to individuals, couples, and families. 

Our counseling program is ongoing and running virtual sessions. Please fill out this entire form to the best of your knowledge. If you are using a proxy (a separate individual different from the identified client) to complete this form please be sure to complete the form with the potential client's information. TCC will process the form once it is submitted and a counselor will reach out to you.

Please note that TCC does not accept insurance but fees for counseling services will be on a generous sliding scale with fees starting as low as $5.00 depending on income.

Question Title

* 1. First Name Initial

Question Title

* 2. Last Name

Question Title

* 3. Contact Information

Question Title

* 4. Are you currently homeless, living in a shelter, or looking for stable housing?

Question Title

* 5. Date of Birth

Date

Question Title

* 6. What is your age?

Question Title

* 7. Which race/ethnicity best describes you? (Please choose only one.)

Question Title

* 8. What term best describes your gender identity?
**cisgender refers to people whose gender identity matches their sex assigned at birth.

Question Title

* 9. Pronouns

Question Title

* 10. What is your sexual orientation?

Question Title

* 11. Which of the following best describes your current relationship status?

Question Title

* 12. Which of the following categories best describes your employment status?

Question Title

* 13. Are you already in therapy?

Question Title

* 14. Are you interested in individual, couples, and/or family counseling? Please check the boxes that apply.

Question Title

* 15. Please provide a 1-2 sentence statement on your reason for seeking therapy.

Question Title

* 16. What is your availability on Mondays? Please check all times that apply.

Question Title

* 17. What is your availability on Tuesdays? Please check all times that apply.

Question Title

* 18. What is your availability on Wednesdays? Please check all times that apply.

Question Title

* 19. What is your availability on Thursdays? Please check all times that apply.

Question Title

* 20. What is your availability on Fridays? Please check all times that apply.

Question Title

* 21. Would you be interested / available for sessions during the weekend?

Question Title

* 22. Please let us know if you are in need of additional services!

Thank you for completing this form. A TCC staff person will reach out to you shortly to follow-up.

T