New Client Inquiry Form

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CURRENTLY NOT ACCEPTING NEW CLIENTS & CURRENTLY NOT CARRYING A WAITLIST

If you're ready to inquire about scheduling, please provide some information about yourself to help Haley confirm that she is a good fit for you as a therapist. She will review your response and will typically respond within 2-3 business days.

Full Legal Name *

Date of Birth *

YYYY

Email *

Phone Number *

Address of Residence

This information will allow me to complete your intake information quicker if we move forward with scheduling.

What is bringing you to counseling? *

Your Availability For Scheduling? *

Will you be using your insurance? *

Yes - Anthem PPO (Employer provided Plan)

Yes - Aetna PPO (Employer provided Plan)

Yes - United Health Care PPO (Employer provided Plan)

Yes - Lyra Health EAP

No - Self Pay (I do not plan to use Out of Network Benefits either)

Other:

Insurance Plan Member ID

Do you have any ongoing legal proceedings at this time? *

Custody, Parenting Mediation, CPS Investigations, Criminal Charges, Open Civil Case, Disability Filings, etc.

Yes

Maybe

Other:

Please provide any questions or extra information here:

PLEASE READ: By submitting this form and therefore submitting your information, you acknowledge and accept the risks of communicating your Private Health Information via unencrypted email. By clicking “Submit” you consent to Life Pathways Therapy, LLC communicating to you, from the non-secure email address provided, regarding Protected Health Information related to the scheduling and/or inquiries of therapy services.

I Understand and Agree

Submit

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This form was created inside of Life Pathways Therapy.