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
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.

Therapist
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?*

Insurance Information:
Please select Legal Sex assigned at Birth (This is an insurance requirement)

FemaleMale
Client's Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Primary Insurance*
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:

Availabilty