Initial Contact Form

1

Name

First Name

Last Name

2

EmailSometimes our emails go to spam, but this is often our first mode of contact. Please keep an eye out for emails.

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Is it ok to leave a message on this number?

Yes

No

5

Is it okay to text this number with information on therapists and links to schedule?

Yes

No

6

Are you wanting therapy for:

Individual

Minor

Couple

Family

7

How old is the minor that you are requesting therapy for?

9

Please describe any relevant custody, divorce, or parental responsibility orders in place.

10

Please share a little about why you are seeking therapy at this time:

11

Do you have insurance? Which?

12

What is your Medicaid Number?

13

Do you want services:

In-person

Online

Either

14

Do you have any scheduling requirements that are important to know?

15

Are you open to seeing an intern?We currently employ interns from Marriage and Family Therapy programs, who are in internships at the end of their programs. They are excited, creative, and bring a lot of new therapist energy and ideas to their work. They receive supervision both through their college and through Instilling Light. Interns can accept some insurances or have low sliding scale options available.

Yes

No

Tell me more about interns

16

How did you hear about us?

Google

Facebook

Insurance Company

Other

17

Anything else important that you would like to add?