Therapy Intake Form
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Email *
First Name *
Last Name *
Best phone number to reach you or client *
For whom are you seeking services? *
Required
Name of client if not seeking services for yourself
Client age *
Client location *
If you are seeking services for an individual under 18 years of age, are there other parents/guardians who need to consent to therapeutic services? *
What condition are you needing help with? *
Required
Have you been in therapy before? *
Day of the week available for session? (Check all that apply) *
Required
Time of day available for session? (Check all that apply) *
Required
What platform do you prefer? *
Which clinician are you interested in working with? *
Required
How did you hear about us? (If doctor or clinician referred you, please fill out their name in "other") *
Required
Please note, we are out of network with all insurance companies. We can provide a superbill for you to get reimbursement from your insurance company.  Payment is required at time of treatment. *
Required
I allow Beth Brawley to contact me via email or phone to connect about possible treatment. *
Required
Do you prefer to be reached by phone or email? *
Required
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