Welcome to Storybook Wellness Center!
Sign in to Google to save your progress. Learn more
Please keep in mind that communications over the internet are not 100% secure. Although it is unlikely, there is a possibility that information you include in this form or subsequent emails could be intercepted and read by other parties besides the person to whom it is addressed. Please be aware of this risk when making the decision to send Protected Health Information over the internet.  Dr Mooney does use the HIPPA compliant version of Google Suite and has signed a BAA with google to protect your PHI under those provisions.  If you prefer to submit this information a different way, please contact Dr. Mooney at drmooney@storybookwellnes.com to discuss options. *
Required
Name *
Email *
Phone number
What Services are you interested in at this time?
If you are looking for any services other than psychotherapy services (such as Supervision/Consultation, Trainings/Retreats, Mediation, or Parenting Time Expeditor Services, please describe those below.  You may then submit the form.  If you are looking for psychotherapy services, please fully complete the rest of this form.  Thank you! For those looking for services other than Psychotherapy Services, please describe here. For those looking for psychotherapy services, please put NA and continue with the rest of this form.
Dr. Mooney typically is available to see patients Tuesday-Thursday (some Mondays) between the hours of 830 am and 2pm.  Dr. Mooney does not have regular after school or evening appointments available.  Appointments are typically scheduled WEEKLY for approximately 55 minutes.  Do these appointment parameters work for you? *
If you have limitations on days or any other appt limitations, please describe them below.
Are you looking for Telemedicine or Face to Face counseling (Storybook Wellness Center offers both or a hybrid) *
Do you plan to use insurance? If so, what is your primary insurance company. Please pull out your insurance card and write specifically what insurance is listed on the card. Please DO NOT include your insurance numbers, just the name of your insurance company. Thank you! *
Do you have any secondary insurance? If so, please list below. Please pull out your insurance card and write specifically what insurance is listed on the card. Please DO NOT include your insurance numbers, just the name of your insurance company. Thank you! *
Please briefly describe why you are seeking therapy and what you are looking for in a therapist. *
Dr. Mooney will reach out to you via email once she receives this form. Do you consent to receive an email from Dr. Mooney *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Storybook Wellness Center.

Does this form look suspicious? Report

Google Forms