Therapy Request Form (Scott Donovan, LMFT)
Please complete the form below.
Please Be Aware: Due to the COVID-19 crisis, we are only conducting Video/ Telehealth sessions currently, via an easy-to-use secure portal. Please check this box that you are aware of this temporary change.
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Email *
Is this for *
Please tell us briefly what is bringing you to counseling: *
Name of client (First and last name) *
For children under 18, please list the name of the guardian (not a minor type NA) *
Main Client's Date of Birth: *
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Phone number: *
Insurance *
Insurance name and Insurance ID/ Member Number. If Cash pay put "I agree to pay cash for sessions". *
Are you ready to schedule a session or do you have questions about how to begin? *
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