Name
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First Name
Last Name
Phone
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Email
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Confirm Email
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Insurance Provider
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Would you like a courtesy insurance benefits quote?
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A quote of benefits does not guarantee payment.
Primary Insurance Company:
Member ID:
Group Number:
Name of Patient using Insurance:
First Name
Last Name
Date of Birth of Patient using Insurance:
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I am interested in counseling for (check ALL that apply):
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Presenting Concern(s) (check ALL that apply)
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I am considering these approaches (check ALL that apply):
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Counselor Preference?
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Message
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Please give us a short description of your presenting concern so that we can match you with the best counselor for your needs. Also, include your insurance carrier, if not listed above.
Time Preferences
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Clients with more flexible schedules typically have a shorter wait time. Evening and weekend appoints are typically booked far in advance. Select all that apply.
How did you hear about us?
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Consent Acknowledgment:
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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.
By sending a message, you consent to being contacted by this practice or via email, phone, or voicemail.
By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.
