New Client Interest Form
Please complete the form below to help us learn a bit about what you’re looking for. 
To ensure that we can match you with the right support, please complete all sections before submitting.
Sign in to Google to save your progress. Learn more
Email *
I am interested in (check all that apply): *
Required
For: *
Please provide the legal first and last name of the person you are seeking services for (the client): *
Client's preferred name:
Client's date of birth: *
MM
/
DD
/
YYYY
Please provide your first and last name (if different from identified client):
Your phone number: *
If you are looking for couples counseling, please provide the following information for your partner:
- first and last name
- date of birth
- email address
- phone number
Have you received services at The Holistic Heart in the past?  *
Please provide a brief description of what you're looking for support with. If there are any specific therapeutic approaches that you’re interested in, you can note those here as well:
 *
What state are you located in? (please note: licensing laws only allow us to see clients living in RI and MA) *
Our clinicians take a holistic, integrative approach to care. Does this approach align with what you’re looking for?
 *
We understand that provider fit is essential to effective therapy. Please share what helps you feel most comfortable and supported in a therapeutic relationship, including your preferences for communication or interaction style (for example: direct, straightforward, gentle, nurturing, etc.).
 *

If you do not plan to use insurance for sessions, or are seeking assessment services (which are not covered by insurance), please select “Self-Pay” in the dropdown menu below.

If you do plan to use insurance for sessions, please select your insurance provider from the list of accepted plans.

Important note: Our providers are not in-network with Medicare plans (including those administered through commercial insurance carriers listed below) and therefore cannot accept Medicare coverage.

 *
Required for insurance clients: Please provide your Member ID so we can verify your coverage details. (If self-pay/ assessment, type “N/A”)
 *
Is there a specific provider you are interested in working with?
Please note that not all of our clinicians currently have openings, but this information helps us understand what you’re looking for in a provider so we can offer the best possible match.
 *
 You can view provider bios on our website: www.holisticheartri.com
Are you currently experiencing any of the following? (check all that apply) *
Important note: This form is not a substitute for crisis support.
If you are feeling unsafe or experiencing a psychiatric emergency, please call 911 or go to your nearest emergency department.
Required
If you selected any of the above, please describe briefly below. If none apply, you can write “N/A.”
 *
Are there specific scheduling needs we should consider when setting up your appointment time (i.e. mornings before 12pm, specific days of the week, etc.) ? *
Are you looking for in-person or telehealth sessions? *

Do you have any accessibility needs we should know about? 

(Examples: sensory sensitivities, communication access needs — e.g., emails are better than phone calls — mobility accommodations, etc.)

How did you hear about us?  *
Thank you for sharing this information - it helps us connect you with the provider who is the best fit for your needs.

Keep an eye on your inbox! A member of our team will reach out to you soon.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Holistic Heart.

Does this form look suspicious? Report

Google Forms