New Client Signup
This form should take less than 5 minutes to complete.
All information submitted is encrypted, secure (SSL & this form feeds into a HIPAA compliant and encrypted version of Google for Work). After you fill this form out, it may take us 24 hours at most to respond as we also check your insurance benefits. Sometimes we can get people in as quickly as within a few days but this varies from week to week and by provider. (Note: If you are in crisis, please call 911)
Are you making this appointment for yourself? *
(If you are seeking an appointment for someone 18 years or older, they must complete the registration form.)
Client's first name *
Your answer
Client's last name *
Your answer
* If you are wanting couple's counseling, please enter your partner's first name and last name
Your answer
* If you are seeking counseling for your child, please enter the guardian's first and last name
Your answer
Client's email *
Your answer
Client's phone number *
Your answer
Client address *
Your answer
City *
Your answer
Zip code *
Your answer
DOB *
(if this is for a minor, put their DOB)
Your answer
Employer *
Your answer
Who is your current doctor/psychiatrist? *
Your answer
Emergency contact with name & phone number *
Your answer
Briefly tell us why are you seeking counseling? *
Your answer
How did you hear about us? *
(This helps us efficiently spend our marketing budget)
Required
What times work for making an ongoing appointment? *
(morning, lunch, afternoon, evening)
Your answer
What is the best way to communicate with you about scheduling? *
After hitting the "next" button below, please note that you may need to scroll up to start the next part of of our singup form. *
Required
Do you plan on using insurance benefits? *
We only take BCBS, Whole Foods, and Flatwater Foundation. If you need out of network, we can give you the forms to file with your insurance company or you can use the app Better (iOS) to file them for you.
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