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New Client Submission Form
Complete the form below in order to be automatically added to our waitlist. Someone from our team will reach out when we have an opening with the best provider for you!

Please note: forms submitted with incomplete information are not able to be added to our waitlist.
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Email *
Legal first & last name: *
Preferred name:
Phone number: *
Date of birth: *
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Have you received services at The Holistic Heart in the past?  *
Please tell us a little bit about what you are looking for support with: *
What state are you located in? (please note: licensing laws only allow us to see clients living in RI and MA) *
Our clinicians specifically take a holistic approach to treatment. Is this something you are open to? *
As a holistically-oriented practice, our providers have a range of expertise. Is there a specific approach that you are looking to incorporate into your sessions? (check all that apply) *
Required
Tell us a little bit about what works best for you as far as a provider's interaction style (i.e. I'd I prefer to work with someone who is direct, offers feedback, is compassionate, nurturing, etc.) You can reference what you have liked or not liked about working with providers in the past if applicable: *
If you are planning to use insurance for sessions, what type of insurance do you have? Accepted insurance plans are listed below (for Neighborhood Health Plan please specify whether it is a commercial or medicaid plan).
**Important note: our providers are not in-network with and therefore unable to accept medicare plans, even if it is through one of the commercial insurance providers listed below.
 *
Please enter the Member ID from your insurance card (this allows us to verify benefits for services and is required in order to be added to waitlist): *
Is there a specific provider you are interested in working with? (Please note: not all of our clinicians currently have openings, however this information is helpful to us in understanding what you are looking for in a provider and we will work to offer you the closest match possible) *
 Provider bios are available on our website: www.holisticheartri.com
Are you currently experiencing any of the following: *
***IMPORTANT NOTE*** This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 911 or visit your local emergency room.
Required
If you endorsed any of the above, please describe here. If you checked "none of the above" simply write n/a here. *
Are there any specific scheduling needs we should consider when setting up your appointment time (i.e. mornings before 12pm, specific days of the week, etc.) ? *
Are you looking for in person sessions or telehealth video sessions? *
Language preferred: *
How did you hear about us?  *
Thank you so much for this important information, as it helps us better determine the right match for you in working with one of our providers! We will reach out to you when we have an opening that meets your needs.
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