Open Path New Client Form
Please complete this form to inquire about beginning therapy services. You will receive a follow up within 48 business hours from your submission.
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First and last name *
Preferred name
What is your date of birth? *
MM
/
DD
/
YYYY
Open Path Member ID *
Please provide your phone number and email address: *
What is your preferred method of communication? Please check all that apply: *
Required
If calling is your preferred contact method, is it safe/okay to leave a voicemail?
Clear selection
Gender assigned at birth *
Preferred gender
Clear selection
Have you seen a therapist before? *
What brings you to therapy? *
Please provide amount per session that financially works for you ($40-$70 per Open Path guidelines) *
What is your availability? *
Required
How often are you interested in having appointments?
Based on the Open Path rate ($40-$70/session), please indicate feasible cost for service: *
Is there anything else you would like me to know prior to our first meeting?
Submit
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