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.
Client's Name (Last, First)
Best phone number to reach client (or parent/guardian)
Client's Date of Birth
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
Kara Cobb (Accepting New Clients)
Brian Kelley (Accepting New Clients)
Please send me a couple/few therapists that meet my needs, and I will choose from among them.
Christine Nicklos (Art Therapy)
Chaunte' Wilder (Accepting New Clients)
Giuseppina Impellizerri (Art Therapist)
Ely Garcia (Accepting new clients/couples/and families, English and Spanish speaking)
Julie Murphy (Art Therapist, Accepting New Clients, Teleahealth only)
Tammy Bobel (Not Accepting New Clients)
Leslie Grange (Sliding Scale Available)
Charita Graham (Accepting New Clients)
Please connect me with the therapist you think is the best fit, given my schedule, needs, and insurance.
Amber Myers (Accepting new clients, Art Therapist)
Marla Cardenas (Sliding Scale Available; English and Spanish speaking)
Annie Novotny (Art Therapist, Trauma Informed)
Olivia Brooks (Accepting New Clients)
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.
Mon -Fri Mornings (8am-noon)
Mon -Fri Afternoons (noon-5pm)
Mon -Fri Evenings (5-10pm)
Saturday Mornings (8am - noon)
Saturday Afternoons (noon-5pm)
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.
Telehealth (video counseling via our secure platform)
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