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Client information request for SoCo Counseling, LLC
Please complete information to be added to our wait-list or for insurance verification.
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Email
*
Your email
First and Last name of client
*
Your answer
Client date of birth
*
Your answer
First and Last name of parent
Your answer
Are you committed to doing weekly sessions in order to get the best results from therapy?
*
Yes
No
Other:
Client phone number
*
Your answer
Parent phone number
Your answer
client email
Your answer
parent email
Your answer
what is your insurance plan name?
*
Your answer
what is your insurance plan number?
*
Your answer
are you willing to do self-pay if we do not take your insurance? each session is $160. Your insurance may have out-of-network benefits. Please contact your insurance company.
*
Yes
No
if using insurance, do you have a deductible?
*
Yes
No
not sure
if using insurance, do you need pre-authorization?
*
Yes
No
Are you willing to have a daytime appointment?
*
Yes
No
Do you prefer virtual or in-person appointments?
*
in person
virtual
either
What is the main concern or focus you are wishing to address in therapy?
*
Your answer
Do you have any other questions or concerns?
Your answer
Preferred time of appointment
*
morning
afternoon
evening
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