Initial Inquiry Form

Initial Inquiry Form

Ed Geraty LCSW-C, LICSW
Basic information:

I work through one of four different teletherapy platforms, INSITE Integrative, Headway, Uplift, or Sondermind, depending on your insurance and state of residence. I am licensed to provide psychotherapy in WV, VA, MD, FL, VT, DE and DC. Once you complete the following information and submit this form, I can let you know which of the four platforms I can see you through. If I am able to see you, I will add your contact info into the appropriate teletherapy platform and let you know that is completed. You will then get a registration email from that platform.
Date of today

MonthDayYear
Date
Email
example@example.com
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number where you can recieve text messages
Please enter a valid phone number.
State where you reside
Name of your insurance carrier (be specific)
Please be aware that I would not be able to tell you what your deductible or co-pay will be for individual and/or group psychotherapy. That depends on your specific insurance policy. Please contact your insurance carrier and ask what your deductible and/or coo-pay would be for out patient psychotherapy services.
After submitting this form I will text you with instructions as to how to register and make your initial appointment. Please text me at 410-804-1934 and let me know you have completed this form. Ed Geraty
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Initial Inquiry Form

Basic information:

After submitting this form I will text you with instructions as to how to register and make your initial appointment. Please text me at 410-804-1934 and let me know you have completed this form. Ed Geraty