New Client Inquiry Form
Let us know how we can help you!
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why are you seeking therapy services?
*
What days and times would work best for your sessions?
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Morning Appointments (8AM-11:00AM)
Afternoon Appointments (12:00PM-3:00PM)
Evening Appointments (3:00PM - 8:00PM)
Do you prefer in-person or telehealth sessions?
*
Please Select
In-Person
Telehealth
Do you prefer a male or female therapist (if possible)?
Please Select
Female
Male
Either
Doesn't matter - but I am non-binary
Do you know who you would like to work with (if possible)?
Please Select
Rachel Soto
Candice Beggs
Kurt Rivera
No Preference
Visit our website at www.tranquiljourneytherapy.org to learn more about our therapists!
Our therapy dog-in-training is usually in the office, bringing extra warmth and comfort—just let us know if you have any allergies or prefer a dog-free space, and we’ll make sure you’re comfortable. 🐾
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No problems here! Bring on the puppy!
I prefer to have sessions in animal-free space.
I prefer to have sessions by telehealth.
If the appointment times you selected are not available at this time, would you like to be added to our waitlist?
*
Please Select
Yes
No
I'd like information on other practices that may have the days and times I need
Do you have insurance (including Medicaid)?
Yes
No
What Insurance Do You Carry? (type N/A if you do not)
*
What is/are the Insurance ID/Member ID/Group Numbers? (type (N/A if you do not have this)
*
Please Upload an Image of Your Insurance Card
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