New Patient Request
.:Intake request form to be matched with an Anchor Clinic clinician:.
Date of Birth
Are you interested in telehealth services at this time?
Please provide a general description of what you are currently struggling with. Any information shared here will only be available to the clinic staff as well as yourself (and anyone with access to your email should you request a copy of your responses today).
What days and times would work best for your sessions? Choose all that apply.
Flexible: Requesting Messaging Therapy
Do you currently have insurance with mental health coverage? If yes, please provide the type of insurance that you currently have. Insurance is NOT required to be considered for an intake.
Are you interested in messaging based therapy plans (private pay only at this time)?
Thank you so much for reaching out! We look forward to supporting you in any way we can. We will be in touch soon. Please send any questions to: email@example.com
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of The Anchor Clinic.