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. 

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 with in 5 business days.

Payments and Insurance: Currently, TCC is not accepting insurance or payment for services. You will be notified before any changes are made and fees are processed.  

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* 1. First Name Initial

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* 2. Last Name

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* 3. Contact Information

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

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* 5. Date of Birth

Date

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* 6. What is your age?

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

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

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* 9. Pronouns

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* 10. What is your sexual orientation?

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

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

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* 13. Are you already in therapy?

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

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

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

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

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

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

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

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

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

Thank you for completing this form.

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