Respark Client Inquiry Form
Welcome to Respark, We're so glad you're here. Please fill out the information below to take the first steps toward working together. Next, we'll contact you to schedule your first appointment.
Full Name *
Your answer
E-Mail Address *
Your answer
Best Contact Phone Number *
Your answer
May we leave a message at this number? *
How would you like to be contacted? *
How did you hear about us?
If another clinician or friend referred you, may we have your permission to thank them for the referral?
What times are you available to come in for a weekly appointment? *
Keeping in mind that sessions usually last about 50 minutes, select all that apply
Morning
Midday
Afternoon
Evening
This day doesn't work for me
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Given that the appointment time is available, When would you like to come in for your first appointment? *
MM
/
DD
/
YYYY
Time
:
Some of our clinicians offer sessions online. Please indicate here if you would like to request this option.
What type of therapy are you looking for? *
Tell us about your ability to pay
Our services start at $125 per session for individual and $150 for couples. We do offer discounts on a limited basis. Additionally, Respark is currently offering service to those using their out of network benefits which means you can submit a receipt (called a superbill) to the insurance company receive reimbursement for out of pocket payments directly from them. You can call your insurance company to see if your plan has out of network beinfits. Please check with your provider to verify your benefits. We also accept health savings accounts and flexible savings accounts. If you’d like more information about options for payment, please mention it at the bottom of this form.
My ability to pay is: *
Please briefly describe what you would like to accomplish in therapy *
Your answer
Did you find a particular therapist on our website that you would prefer to work with? Please note with online sessions, you must have address of the state listed next to the Therapist. *
Do you require any special accommodations?
Anything else you'd like us to know?
Your answer
Thank You!
We appreciate your taking time to fill out this information. You should expect someone from Respark to contact you within the next two business days.
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