New Therapy Client Form
Thank you for considering Freedom First Psychological Services for therapy services. Our therapists are currently full and we are maintaining a waitlist for potential new clients. Please complete the information below as accurately as possible so we can add you to our waitlist and reach out when a spot becomes available that will fit your needs.

Please note that our volume of new client inquiries is quite significant right now and we are not able to call to confirm that we've received your form or to provide frequent updates about your status on the waitlist. When we have a new client spot become available, we will be working through the waitlist on a first come first serve basis, using the information below to identify who would be a good fit for the availability. We will call/email you as soon as we are able to offer an appointment.
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First and last name of the potential client: *
Date of Birth of the potential client: *
What type of insurance does the potential client have? *
Please provide the Insurance ID of the potential client: *
If you are completing this form on  behalf of your client or someone else, what is your name:
Phone Number: *
Email Address: *
Please provide some information about the reasons for seeking therapy? (so we can find the best fit therapist) *
What times of day would be best for appointments typically? (please check all that apply) *
Is there anything else we should know in order to identify a good therapist fit for you? *
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