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Booking and Intake Form
Please fill out the intake form and upload a copy of your insurance card and photo ID. This information is confidential, securely stored, and used solely for verifying coverage and matching with a therapist. If you choose not to proceed, your information will be safely discarded. Providing this information helps schedule appointments within 24–48 hours.
Full Name (First and Last)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Provider
*
Insurance ID Number (including letters if applicable)
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Comments or Message
Consent and Policies
Please read and agree to the following terms before submitting your form. I understand therapy is provided by secure video and audio. I can stop telehealth sessions at any time. Sessions are not recorded and I agree not to record them. My privacy is protected, but internet-based sessions may have some risks, e.g., dropped calls, unauthorized access. I agree to follow backup plans if the video connection fails. My therapist may contact emergency services if needed during a session. Cancellation Policy I agree to cancel at least 24 hours before my appointment. I understand I will be charged $65 for late cancellations and $130 for no-shows. Emergencies or illness may waive these fees. Payment Policy I will keep a credit/debit card on file for balances. Insurance co-pays and balances not covered are my responsibility and due within 30 days. Self-pay clients must pay at the time of service. By signing, I agree to these terms.
Signature (Agreement to Terms)/Firma (Aceptación de los Términos)
*
Firme aquí
Upload Insurance Card and Photo ID/Suba su tarjeta de seguro y una identificación con foto
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Security Check/Verificación de seguridad
Appointment
Cita
Continue
Continue
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