New Client Inquiry Form

Prospective Client Information
Which services are you interested in?
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender Pronouns*

They/ThemShe/HerHe/HimHe/ThemShe/Them
Contact Number:*
E-mail*
example@example.com
What state are you located in?
How did you hear about our services?*
Referring Provider's Name

First NameLast Name
Other: Explain
Services
Which services are you interested in?*

Individual TherapyCouples TherapyFamily TherapyExecutive Leadership Coaching & DevelopmentSupport GroupWorkplace Wellness FacilitationOther
Enter your partner's name:

First NameLast Name
Enter your partner's email address:
example@example.com
Enter your partners phone number:
Please enter a valid phone number.
Are you interested in virtual or in person services?*

VirtualIn Person (Renton Office Location)Unsure
We are located in the Maya Whole Health Office in Renton, WA

1800 NE 44th ST, Renton, WA 98056. We are excited to offer services in another local Black-owned wellness space, Maya Whole Health, in their clinical services office in Renton, WA. Here our clients can find an array of whole health services, including Acupuncture and clinical massage, boutique Pilates classes, and services from other wellness providers.Our office is a short 5 minute drive 2.5 miles north of The Landing in Renton.
If you are not the primary client seeking services, please share who the client.
If the client is a minor, what is their date of birth?

MonthDayYear
Date
Tell us what brings you to Dream Life Out Loud at this time? What challenges are you interested in working on with a provider?*
When are you hoping to begin services?
Payment For Services
For psychotherapy services, we accept Premera, LifeWise, and BlueCross BlueShield insurance. For all other insurance providers, we are considered an out-of-network provider. Clients paying out of pocket may request a Superbill to submit for eligible out-of-network reimbursement. We accept all major credit cards, as well as Health Savings Account (HSA) and Flexible Spending Account (FSA) cards. Payment is required prior to the time of service.*

Self Pay: Out of PocketOut of Network Superbill Reimbursement (Therapy only): Out of PocketPremeraBlueCross BlueShieldLifeWise Health Plan of WashingtonLyra Employee Assistance Program
Who is your insurance provider?
Member/Subscriber ID
Group Number
Policyholder’s Full Name
Policyholder’s Date of Birth

MonthDayYear
Date
Relationship to Policyholder
Upload a Copy of Your Insurance Card

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*Please note: Thanks for your interest in working with us! Since you’re not using insurance, your request will be redirected to Danielle Henry, LLC — our sister coaching and wellness brand. This allows us to better support you with services outside of clinical care. You’ll receive a follow-up message directly from our coaching team (via HoneyBook) to explore next steps. Please note: HoneyBook is not a medical records system, but it’s secure and designed for wellness and consulting services.
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Prospective Client Information

Services

We are located in the Maya Whole Health Office in Renton, WA

Payment For Services