New Client Inquiry Form

Prospective Client Information
Name*

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Date of Birth*

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Contact Number:*
E-mail*
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What state are you located in?*
How did you hear about our services?*
Referring Provider's Name

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Services
Which services are you interested in?*

Individual TherapyCouples TherapyFamily TherapySupport GroupOther
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Are you interested in virtual or in person services?*

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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?

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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 in-network with Premera, LifeWise, Aetna and First Choice Health Network (Kaiser, Providence Health Plan and PacificSource Health Plans) 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
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Policyholder’s Full Name
Policyholder’s Date of Birth

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Relationship to Policyholder
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*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.
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Prospective Client Information

Services

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

Payment For Services