Client Screen Match
 

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Email *
Today's Date *
MM
/
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Client Name *
Contact Phone number *
Are you looking for services for you or someone else? *
Required
Date of Birth *
MM
/
DD
/
YYYY
Name of person who is seeking services if other than yourself.
What service(s) are you looking for?
What insurance do you have?
Session Time Preferences *
Required
Session Preferences *
Required
Day preferences *
Required
Do you have a preference in male or female therapist?  *
Required
Communication *
Required
Why are you seeking services?  *
Required
Have you engaged in therapy before? *
Are you currently on any psychiatric medications? *
Have you been diagnosed with any of the following? *
Required
How did you hear about R&R Healing Co.? *
Required
Is there someone specific @ R&R Healing you want to see?
For therapy only—What is your preferred frequency for scheduling sessions? *
Required
Is there anything else you want to us to know?
Did you send the following information to info@restorehealing.org?

Email us this information so we can set up patient portal, so you electronically sign intake forms:

-Front & back of insurance card
-Date of Birth and full names for dependent(s) 
-Phone number
-Photo ID (for verification purposes)
-Need current address if different from ID
-Policyholder full name, date of birth, and address of policyholder if different than yourself
info@restorehealing.org
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Required
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