New Client Interest Form
Thank you for your interest in working with a psychologist or CBT therapist through Atlanta CBT.

Please take a few moments to help us learn what you are seeking. 

***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.***

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How did you hear about Atlanta CBT? *
Are you filling out this form for yourself or another person? *
What is the first and last name of the potential client?

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Date of birth of the potential client *
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IF you are filling this form out on behalf of another person, what is your name and relation to the potential client? 
Phone number of potential client (or parent/guardian if potential client is a minor) *
By checking this box you agree to receive text messages for scheduling purposes at the number above. Standard message and data rates apply. By submitting this form, you agree to our Terms and Conditions and Privacy Policy.  *
Required
Email address of potential client (or parent/guardian if potential client is a minor) *
Please confirm your understanding of the following: 

Atlanta CBT is not in-network nor do we bill directly any health insurance plans. 

***This means... WE DO NOT ACCEPT INSURANCE. Also, therapy through Atlanta CBT is NOT COVERED by Medicaid or Medicare.***

Clients must pay for sessions with a credit/debit card or HSA card.  

Our rates are listed on the "Services and Fees" page of our website. Therapy and parent training costs $225-$265 per session and the intake will cost $367. For weekend appointments, there is a charge of $50 extra.

We do offer monthly super bills, upon request, for clients with out-of-network benefits who wish to file for reimbursement on their own. We do not file on behalf of clients. You may consult with your insurance company to learn about your benefits.

Please confirm that you have reviewed the fees and are willing and prepared to pay out of pocket.
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Please confirm the following rates of our independent contractors:

60-Minute Intake Session $367 (+$50 if on weekend)

53-Minute Individual Therapy Session or Parent Training Session

With Heidi M. Wood, L.C.S.W.  $225

With Beth Hammons, Ph.D., ABPP $265 (+$50 if on weekend)

With Leah Farrell-Carnahan, Ph.D., $265

With Julia Buch Wamstad, Psy.D., $265

With Nathan Mascaro, Ph.D., ABPP,  $265

With Rochelle Holtzman, Ph.D. $265 (adult) – $312 (minor) | minors/parents of minors typically do 45-minute individual therapy sessions at a cost of $265

With Parham Horn, Ph.D., $265

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What state/s will the potential client be located in  during participation in therapy? *
Please describe the potential client's 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 severe substance dependence requiring medical detox and medical treatment, unmedicated bipolar or psychotic disorders, or active suicidal behavior and intent. We do not provide child custody evaluations, documentation related to legal claims (e.g., disability, damage, or custody claims), court testimony regarding custody, court-ordered treatment, or workers' comp assessment or treatment.**
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Has the potential client ever engaged in self-injurious behavior (cutting, etc.). This does not include skin picking or pulling out one's hair.         *
Has the potential client ever thought they would be better off dead and or had thoughts of suicide?     *
Has the potential client been hospitalized for mental health reasons? *This includes residential treatment for mental health or substance abuse. *
What is the potential client's availability for appointments? 

Please indicate specific days/times that are preferred or required.  

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We offer therapy both in person and via telehealth. Availability will vary depending on therapist.
Please check all that apply...
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Required
For in-office services, please also note that our offices are not ADA accessible. There are stairs and no elevator.
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Is there a specific therapist you would like to work with? 

If you are interested in working with a specific therapist, please review their availability, including their in person/telehealth availability. 
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