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 GroupOther
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 are considered an out-of-network provider and clients pay for services out of pocket. We offer Superbills for clients to submit an insurance reimbursement for eligible out-of-network benefits. We accept all major credit cards, Health Savings Account (HSA) card or Flexible Spending Account (FSA) card. Payment is required before the time of services. How will you be paying for services?*

Self Pay: Out of PocketOut of Network Superbill Reimbursement (Therapy only): Out of Pocket
Should be Empty:

Prospective Client Information

Services

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

Payment For Services