New Client Paperwork
Prior to arriving at your first appointment, please fill out the following and click "submit". If you plan to use insurance to pay for your services, The Center for Self-Actualization will verify your benefits before your first session.
Clear selection
Client's Name (Last, First) *
Best phone number to reach client (or parent/guardian) *
Client Email *
Client's Date of Birth
MM
/
DD
/
YYYY
What is your preferred method of contact? (By checking one of the following you are consenting to being contacted in that way.) *
Will you be using insurance to pay for services? *
If no, please skip the remainder of the questions below.
Insurance company name:We are in-network with BCBS PPO, Blue Choice PPO, TraditionalBlue, or BasicBlue.
If we are not in-network with your insurance provider, we will verify your out-of-network benefits and/or work with you on a sliding scale if needed.
Insurance Policy Holder's Name
Member ID #, Including the three character prefix
Group #
Requested therapist *
What would you like to address in therapy? *
A sentence or two will do. (e.g., depression, anxiety, marriage problems. . . )
When are you available for therapy? *
Please check all that apply.
Required
How did you hear about The Center for Self-Actualization?
In just a few words
Which location would work best for you. Please select all that apply. The more you select the more therapists may be available to work with you. *
Required
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