New Client Request
If you need immediate assistance, do not use this form.  Please call 911, go to your local emergency room, or call the Foundation2 Crisis Hotline at 1-800-332-4224.
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If you have been seen previously at Alli Center, do not use this form. You may call us at 319-804-9312 or email us at scheduling@alli-center.com to request to work with us again.
Note: By emailing us, you are giving your consent for a response by email, understanding that email may not be encrypted and even if encrypted, email poses security risks that threaten confidentiality (i.e., other people reading your messages, hacking and email pirating, lost or stolen devices). If you would prefer a response in another format (telephone, voice mail, FAX, or postal service), please indicate your preference by contacting us by any of these other methods.
What kind of services are you looking for?
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Client's First Name *
Client's Last Name *
Parent or Guardian's Name
Client's Date of Birth *
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DD
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Client's Legal Sex (for insurance purposes) *
Patient's Gender Identity (if different)
Email Address (by giving us your email address, you authorize us to reply to you by email)
May we send you email messages at the above address?
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Phone Number *
Is it OK to leave a voice mail message at this phone number? *
What is the best time to reach you by phone? *
Would you prefer to sign paperwork electronically or on paper? (We are unable to schedule your first appointment until we have received your signed paperwork.) *
Primary Insurance Company *
Secondary Insurance Company (if applicable)
Issues & Goals
Check the boxes of any issues you want to work on.  This information will help us decide which provider might be a good fit for you.
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Required
Issues & Goals
What do you want to work on with us? Please elaborate on any of the above issues.
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Availability
Are you able to have regular appointments Monday through Friday, 9 am - 4 pm? Please let us know what restrictions you have.
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How Did You Learn About Us? *
Other Comments
If there are any therapists you are particularly interested in working with, please list their names.
We will review your request and contact you at either the phone number or email address you provided above. Please watch your email for a message from us with instructions on how to proceed.
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