New Client On-boarding Form

Please fill out this questionnaire so we can assist you in booking your first appointment:
Name of Potential Client

First NameLast Name
If Child - Name of Parent/Guardian

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Office Location:
Are you seeking therapy for yourself or someone else?

Other
Do you have a preferred therapist you’d like to see?
What type of service are you seeking?
What are the primary concerns/Goals that motivated you to seek therapy? Check all that apply

Other
How do you intend to pay for sessions? (please note that not all of our therapists are credentialed with these insurance companies. Please confirm with your insurance company what services they will reimburse for and if the clinician is in network with them. We can not guarantee coverage even if in network as each insurance plan is unique). **We DO NOT accept Select Health/First Choice and Absolute Total CareMedicaid

Other
Date of Birth of Potential Client

MonthDayYear
Date
Gender on record with insurance
Please upload your insurance card so we can verify your benefits:

Cancelof
Preferred appointment time?
How did you hear about us?
Please verify that you are human
Should be Empty:

Please fill out this questionnaire so we can assist you in booking your first appointment: