New Patient Inquiry
This brief questionnaire is designed to match you with the right therapist and get you started as quickly as possible. Once you submit, we will be in touch with answers to your questions and next steps. If you have any questions or run into any difficulty, please email kate@h1therapy.com. Thank you ~ we look forward to serving you.  
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First and last name:  *
Email: *
Date of birth:  *
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SERVICES
What type of services are you seeking? *
If you are seeking therapy for someone else, please provide their first and last name(s) here: 
Is there a particular therapist you are hoping to see? (Please keep in mind availability depends on several factors, but we will do our best to accommodate your wishes).
Is there anything in particular you want or need in a therapist?
SCHEDULING 
Which location would work for you? (Please select all that apply)  *
Required
We strongly recommend starting therapy at least weekly. Are you able to make that commitment?  *
What time slots would work for you on a weekly basis (Please check ALL that apply)?
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
FINANCES 
Are you hoping to use your insurance for therapy? *
If you would like to use insurance, which insurance coverage do you have?
Clear selection
ADDITIONAL INFORMATION 
How did you hear about us? *
Is there anything else you feel we should know about you from the start?
Do you have any other questions you would like answered right away? 
On a scale of 1-5, how ready to you feel to begin therapy?
Hesitant
Very
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