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Nursefully New Client Interest Form

Thank you for your interest in working with a Nursefully therapist!

This form will help us gather a few details before scheduling your free 15-minute call with a therapist. During the call, we’ll answer your questions, discuss what you’re looking for, and help you take the next step.

We look forward to connecting with you!

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Note: If you are experiencing a medical or psychiatric emergency, or if you need immediate assistance, please contact emergency services immediately.

Emergency Contacts:

Call 911 for immediate assistance.

National Suicide & Crisis Lifeline: Dial 988

National Domestic Violence Hotline: 1-800-799-7233 (or text START to 88788)

The Trevor Project (for LGBTQ+ youth): 1-866-488-7386 or visit https://www.thetrevorproject.org
Which therapist are you interested in working with? *
Full Name *
Preferred Name
Email Address *
Phone Number *
Are you a nursing professional?
(includes but not limited to nursing students, CNA, LPN, LVN, RN, APN, NP, CNS, CRNA, CNO, nurse midwives, leaders, educators, and retired nurses)
 *
Where do you plan to receive virtual therapy? 
(This should be the state where you will be physically located during sessions, as licensing laws require therapists to practice within specific states.)
 *
Don’t see your state listed? Let us know where you are!
(We’re always looking to expand our services. If your state isn’t listed, tell us where you’re located so we can keep you in the loop about future availability!)
What brings you to therapy? (select all that apply)
Do you have insurance you'd like to use for therapy? *
(optional) Nursefully therapists partner with Headway, a HIPAA-secure platform that supports credentialing, billing, insurance verification, and documentation. If you would like us to verify your insurance coverage for therapy before your 15 minute call, please provide us with the following information:
Insurance Plan
Insurance Member ID
Insurance Group ID
Date of Birth
MM
/
DD
/
YYYY
Do you allow Nursefully and Headway to use this information to verify your insurance benefits and estimate your out-of-pocket costs?
(This helps us give you accurate copay and coverage information before your first session.)
 *
Required
Is there anything else you'd like us to know before scheduling your call? 
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