New Client Intake Form

This short form helps us learn about what you’re looking for — whether it's support for trauma, anxiety, life changes, or simply a space to be heard. You'll answer a few quick questions about yourself.

Once we receive your response, our intake team will personally review your answers and reach out to you to walk you through what comes next. 

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In which state is the client seeking therapy? *
Preferred Session Format
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Client First & Last Legal Name 
(If you have a different preferred name, please add it in parentheses)  *
Is the client a minor? *
Parent or Guardian Name (If custody agreement is in place, please explain) *
Client Date of Birth
You can type in the date *
MM
/
DD
/
YYYY
Phone Number
(Note: If client is a minor put caregiver's number) *
Email
(Note: If client is a minor put caregiver's email)
 *
Would you like to be added to our email newsletter?  *
Community connections mean a lot to us; we’d love to know how you found your way to us and where that connection started *
If referred by an external professional, please list the name of the therapist, doctor, practice, or organization:
What would you like support with in therapy?   *
Required
What type of therapy or service are you looking for?   *
Required
Please share any additional details about what brings you to therapy right now.
This helps us better understand your situation and match you with the right clinician. *
What health insurance do you have?
(Important insurance notice: We are not in network with any Medicaid or Medicare plans. Your primary insurance must be in network with our practice. If your primary insurance is not in network, insurance claims may be denied and you may be responsible for the full cost of services.)
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  If you have BCBS, which BCBS plan do you have?  
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What is the Member ID Number?
What is the Group Number?
Provide the name of the subscriber for the primary insurance
If the subscriber is not the client, what is their relationship to the client?
What is the Subscribers date of birth for your primary insurance?
MM
/
DD
/
YYYY
Client Gender on Insurance (Required for Billing Purposes)
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What is the Provider Services Phone Number?
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