Interest Form

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Interest Form

Please complete and submit our HIPPA compliant interest form.

Full name of individual filling out interest form *

Are you needing services for yourself or someone else? *

Myself, I will be the client

Someone Else

Myself and Someone Else

What is your primary concern at this time? *

Intended Client's Name *

Intended Client's Date of Birth *

YYYY

Full Mailing Address *

Phone Number *

Email Address *

Our software system sends appointment reminders. How would you like to receive a reminder? *

E-mail

Text

Phone Call

Required

What is your preferred method of communication? *

Text Messages

Phone Calls

Voicemails

Any

Required

When is the best time to contact you? *

Morning

Afternoon

Evening

Any time

Required

Sometimes individuals are living in circumstances were they need communication restricted. Do we need to restrict any of the following? *

N/A

E-mail

Text

Phone Calls

Voicemail

Other:

Required

Our standard rate per session is $150. What payment options are you considering or concerns you might have? *

Cash, Check, Credit Card

Out of Network Provider

I am interested in knowing about your sliding scale so that I can get a reduced rate.

I am afraid I won't be able to afford it.

I need to use insurance.

Other:

Required

If you need Insurance, what insurance company do you need? *

How did you hear about us? *

Is there anything else you would like us to know at this time? *

Submit

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