Appointment Inquiry Form

Appointment Inquiry Form

This form is for Adults and Children clients who are seeking to work with our clinicians.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Communication*

Phone CallTextEmailNo Preference
Therapy Type You are Seeking

IndividualCouple's TherapyFamily Therapy
Are you completing this form for a child/adolescent?*

NoYes
If you clicked yes, please answer the following questions. If you clicked no, you can skip down to the following section.
- Child/Adolescent's Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Are you the primary legal guardian?
  
  NoYes
- Has your child attended therapy previously?
  
  YesNo
- Availabilty
  
  Down below, you will let us know what times work best for scheduling your therapy sessions.
- Monday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)Afternoon (3pm-5pm)Evening (6pm-9pm)
- Tuesday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)Afternoon (3pm-5pm)Evening (6pm-9pm)
- Wednesday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)Afternoon (3pm-5pm)Evening (6pm-9pm)
- Thursday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)Afternoon (3pm-5pm)Evening (6pm-9pm)
- Friday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)Afternoon (3pm-5pm)Evening (6pm-9pm)
- Saturday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)Afternoon (3pm-5pm)
- Sunday
  
  Morning (9am-11am)Early Afternoon (12pm-2pm)
- Please Note: Not all clinicians are available on evenings and weekends.
- Therapist Request: Please select the therapist(s) with whom you would like an appointment*
- If your requested therapist(s) is not available, please tell us your preference*
  
  I would like an appointment with another therapistI would like to be added to my selected therapist's waitlistIf my requested therapist's waitlist is longer than two weeks, I would like an appointment with another therapist.I am open to meeting with any available therapist
- I would prefer a therapist that identifies*
  
  FemaleMaleNo Preference
- How did you hear about Serenity Zone Therapy, LCSW, PLLC?*
- Please tell us briefly why you're seeking treatment. (You do not have to go into detail. A brief summary is sufficient.) *
- Are you employed?*
  
  YesNo
- Are you on psychiatric medication?*
  
  YesNo
- If you checked yes, please list medications below.
- Do you have a history of drug or alcohol abuse*
  
  YesNoOther
- If Yes, please describe.
- Have you ever been psychiatrically hospitalized?*
  
  YesNoOther
- If Yes, please describe
- Are you presently suicidal?*
  
  YesNo
- Do you think of hurting yourself?*
  
  YesNo
- Please select Legal Sex assigned at Birth (This is an insurance requirement)*
  
  FemaleMale
- Client's Date of Birth (MM/DD/YYYY)*
  
  MonthDayYear
  Two Digit Month/Date/Year
- Primary Insurance: (Please Note: If your insurance is not listed below, that means that we are not In-network with your provider and you will be provided with the cash rates for clinicians.)*
- Insurance Member ID Number/Subscriber ID*
- Please upload a picture of the Front and Back of your insurance card to expedite the insurance verification process.*
  
  Cancelof
- Serenity Zone Therapy, LCSW PLLC operates on a strictly virtual basis. That means that all sessions will be conducted via a HIPAA compliant video platform. No in-person sessions will be provided. Please check down below to confirm understanding and agreement to this matter.*
  
  YesNo
- Final Note: The practice will conduct an insurance verification to ensure that coverage is active. Once that is confirmed, a clinician will reach out to you to discuss the scheduling process.
- Should be Empty:

Appointment Inquiry Form

Availabilty