New Client Signup
Please fill out this brief form, and one of our scheduling coordinators will be in touch within 24 hours. All information submitted is encrypted and secure. If you are in crisis, please call 911.
Client Questions
Who is this appointment for? *
Full name *
Client's full name "John Smith"
Your answer
Parent or guardian's name (who is making the appointment)
Client's full name "John Smith"
Your answer
Age *
Client's age
Your answer
Date of birth *
MM
/
DD
/
YYYY
* If you are interested in couple's counseling, please enter your partner's first name, last name, and email address.
Your answer
If you are seeking couples counseling, please put your partners date of birth
Your answer
Phone number *
Contact number for client or person making the appointment
Your answer
Email address *
Email address for client or person making the appointment
Your answer
What is the best way to communicate about scheduling? *
Required
When would you have the ability to come for appointments? *
Please check all that apply
Required
Please tell us briefly why you are seeking support. *
This helps us match you with an appropriate therapist.
Your answer
Is there anything else you would like us to consider when choosing a therapist for you?* *
Your answer
How did you hear about us? *
If someone specifically sent you our way, please list it in "other."
Required
Insurance Questions
**Please only fill out the below if using Whole Foods or if you want us to check out of network benefits for you.
+ You can use Better (better.co) to easily file your out of network benefits.
+ PLEASE FILL OUT ALL FIELDS IF USING OUT OF NETWORK OR WHOLE FOODS.
Which insurance do you have?
Whole Foods or list your insurance company and we will check the out of network benefits
Client's name as it appears on the insurance card.
Your answer
Insured subscriber ID#
Please include the 3 letter prefix if you have one or 9 digit primary number + 2 digit suffix.
Your answer
Insured group #
Your answer
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