Client Inquiry Form

Services
Who are you seeking services for?
Which services are you interested in? (check all that apply)

Other
Name

First NameLast Name
Date of Birth

MonthDayYear
Gender Pronouns
Contact Number:
Format: (000) 000-0000.
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
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.Format: (000) 000-0000.
If you are not the primary client seeking services, please share your relationship with 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?
Availability Preferences
Are you interested in virtual or in person services?
Preferred appointment times?

Other
What days work best?

Other
Payment For Services
Ho do you anticipate paying for services?
For psychotherapy services, we in-network with Premera, LifeWise, Aetna and First Choice Health Network (Kaiser, Providence Health Plan and PacificSource Health Plans) Aetna, Regence, Blue Cross Blue Shield, Optum/United Healthcare insurance providers.

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.
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

Cancelof
*Please note: Thanks for your interest in working with us! If 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.
Client Preferences
Who would you feel most comfortable working with?

Other
Type a question
What made you reach out to Dream Life Out Loud?
Join the Waitlist

Because Danielle is currently at capacity, we are building a priority waitlist for future openings and new clinicians joining our team.
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Other
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Services

Availability Preferences

Payment For Services

Client Preferences

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