Head Heart Therapy Intake Form

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Thank you for your interest in working with Head Heart Therapy. Please allow at least 24 business hours for a response. Please make sure to check your spam folder for emails from intake@headhearttherapy.com. If you do not hear from us, feel free to reach out to that address directly.

Please note that we cannot accommodate mental health emergencies. If this is a mental health emergency, please call 911 or go to your nearest emergency room.

Please consider the following notes before filling out this intake form:

1) We are in-network with BlueCross BlueShield PPO plans, Aetna and United/Optum plans. We do have availability for self-pay clients, and some limited availability for sliding scale.
2) We are currently operating under a hybrid model. Some therapists have in-person availability, but that will be dependent upon a particular therapist's availability.

Email *

Type of desired service (please note service type dependent upon availability) *

Individual therapy (for self).

Relational therapy (for self and partner(s)).

Individual therapy (for dependent).

Group therapy.

Family therapy.

Intensive Retreat.

Legal Name (of client) *

Name (of client; if different than legal name)

First and last name of guardian (if applicable)

Pronouns (of client)

Pronouns (of guardian; if applicable)

Legal sex (of client; why?) *

Phone Number *

May we call this number? *

Yes

Date of birth (for client) *

YYYY

General availability (check all that apply)

Weekday mornings.

Weekday afternoons.

Weekday evenings.

Weekend mornings.

Weekend afternoons.

Weekend evenings.

Is there anything we should know about your schedule?

Do you have a preference for in person or virtual (please note, this will be dependent upon therapist availability)? *

In Person Prefered

Virtual Prefered

No preference.

Insurance Type (note; the Intake Coordinator will require insurance ID card). *

BlueCross BlueShield PPO

Aetna

United/Optum

Uninsured

Other:

State of residency *

Any preferences for the type of therapist you want to see (for example; demographic preferences, approach/orientation preferences)? *

Have you ever seen a therapist at Head Heart before? *

Yes

I'm not sure.

How did you hear about Head Heart Therapy? *

Please briefly describe your goals of therapy. *

Any specific physical accommodations you may need (I.e. Wheelchair accessible, elevator access, etc.)? *

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