Restoring Wellness New Client Form
Thanks for your interest in becoming a new client with Restoring Wellness! Please fill out the following form for the individual that is interested in receiving services. If you are interested in more than one individual receiving services, you will need to complete a separate form for each individual. Thank you!
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Email *
Name of Individual Receiving Services *
Email *
Full Address (Street, City, State, Zip Code) *
Phone Number  *
Date of Birth *
MM
/
DD
/
YYYY
Preferred Gender *
Required
Preferred Method of Contact *
Required
Text Messaging Consent  - Select All to Consent to Receiving Text Messages
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Appointment Availability *
Associated Parties
If the client is under the age of 18, please list one legal guardian below.
If the client is over the age of 18, please list one emergency contact below.
Secondary contact is not required.
Primary Contact Name
Relationship
Phone Number
Full Address (Stress, City, State, Zip Code)
Insurance Coverage/Insurance Type (Include State) *
Have you been a client here before? *
If yes, who was your previous clinician?
Referral/ Preferred Provider Information
How did you hear about Restoring Wellness? *
Reason for Referral: Why are you seeking services and/or what is your primary goal for therapy? *
Please note: Every clinician offers virtual therapy days. While we do our best to accommodate your preferences, some sessions may be held virtually. We share this so you can feel prepared and know what to expect.
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