APPLICATION FOR SERVICES

GENERAL INFORMATION

Thank you for your interest in Seattle Counseling Service.  We are the oldest LGBT mental health agency in the United States, proudly serving our community and allies since 1969.  SCS expanded our services to include alcohol and drug addiction in 2003. 
 
Recently we combined our mental health and addiction intakes into one, comprehensive assessment.  This new tool helps us to determine how best to support you and provide you with the appropriate kind of care. 
 
Items with an asterisk* are required.
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Person completing application *
 
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Are you a returning client? *
Phone Type
Can we leave a message?

FINANCIAL INFORMATION

Are you currently on Medicaid? *
Do you have EIP Insurance? *
Do you currently have Medicare? *
Do you have other insurance? *

Seattle Counseling Service provides services on a sliding scale basis to the extent possible to those in need. Proof of income is required and eligibility is determined by comparing your gross household income to the Federal Poverty Guidelines. Your eligibility is reviewed on an annual basis, and your sliding scale rate may change if you’ve had a change in household income.

We accept the following documents as proof of income:

* Federal Income Tax filing for the previous year

*Two months of paycheck stubs

*Two months of bank statements

If there are two or more adults in the household, documents must be provided for all adults to verify household income. If you feel that you have special circumstances, you may submit a written statement explaining your current situation.

Special funding may be available to you if any of the following conditions apply to your situation. If you wish to be considered for this funding, check any items that apply.

PROGRAMS & SERVICES

Partners will also need to submit a separate application.

Please note:

  • SCS only provides psychiatric medication management to Medicaid clients enrolled in our mental health therapy services.

  • If seeking couple's counseling, SCS requires that all partners complete the assessment and engage in individual therapy (5 sessions minimum) prior to being assigned a couple's therapist.  An exception is made for any partners already receiving therapy outside of the agency.  A release of information with these therapists will be required.
Do you need an assessment/treatment for court or probationary purposes? *
If YES, please note that you will be required to bring appropriate documentation.
 

For a DUI, you will need to provide 3 documents:

  1. A copy of the citation of the evening in question or a copy of the police report
  2. A copy of the breathalyzer results
  3. Your driver’s abstract (available at the Department of Licensing)
  4. Any paperwork from the court in regards to your sentencing, court dates, charges, etc. 

For non-DUI charges please provide:

  1. A copy of the citation or a copy of the police report
  2. A copy of your criminal record or evidence of lack thereof
  3. Any paperwork from the court in regards to your sentencing, court dates, charges, etc.

QUESTIONNAIRE

When are you available for appointments? *
To send us your completed application form, click on the SUBMIT button below.

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