Atlanta CBT New Client Interest Form
Thank you for your interest in becoming a client at Atlanta CBT.

Please take a few moments to help us learn what you are seeking. The information gathered on this form will be used to assess if our services may be a good fit for you and to match you with one of our therapists.

***We see patients ages 12 and up. We offer parent training for parents of anxious children under 12 but we do not offer direct services to anyone under 12 at the current time.***

***This form should only be completed by people who are 18 years of age or older. If you are a minor, please work with a parent/legal guardian to complete this form.***

Sign in to Google to save your progress. Learn more
Email *
Are you filling out this form for yourself or another person? *
If you are filling this form out on behalf of another person, what is your name?
What is the first and last name of the potential patient? *
Date of birth of the potential patient *
MM
/
DD
/
YYYY
Phone number *
How did you hear about Atlanta CBT? *
Please confirm your understanding of the following: We are not in-network nor do we bill directly any health insurance plans. We do offer super receipts for clients with out-of-network benefits who wish to file for reimbursement on their own. Clients must pay for sessions with a credit card, HSA, cash, or check. Our rates are listed on the "Services and Fees" page of our website. Please confirm that you have reviewed the fees and are willing and prepared to pay out of pocket. *
Required
What state/s do you plan to be located in during your participation in therapy? *
Please describe your reasons for seeking services in a a few sentences. The more we know, the better we can determine if we are a good match for your needs. **Please note we are a specialty practice and we are not equipped to help patients with autism spectrum disorders, substance dependence requiring medical detox and medical treatment, unmedicated bipolar disorder, psychotic disorders, active suicidal behavior and intent, and behaviors such as active self harming.** *
Have you ever engaged in self-injurious behavior (cutting, etc.). This does not include skin picking or pulling out one's hair.         *
Required
Have you ever thought you would be better off dead and or had thoughts of suicide?     *
Required
Have you been hospitalized for mental health reasons? *This includes residential treatment for mental health or substance abuse. *
What is your availability for appointments? Specific days/times that are preferred? *
Each of our therapists has a section in their bio page describing their availability (times/days/in-person/telehealth). If you are interested in working with a specific therapist, please review their availability. In general, Atlanta CBT offers services via our secure telehealth portal and in-person. Our office is located in the Inman Park neighborhood of Atlanta. We are following CDC guidelines/ precautions. Please indicate your understanding of this and describe any preferences you might have. *For in-office services, please also note that our office is not ADA accessible; there are two flights of stairs and no elevator.* *
Is there a specific therapist/s on our team that you would like to work with? *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of atlanta-cbt.com. Report Abuse