New Client Intake Form

New Client Intake Form

My Growth Management
Welcome! This short form helps us understand your practice and how we can best support your billing needs.
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Practice Name
Practice Location
How many clinicians are in your practice?
What Services do you bill for? ex. Individual therapy, couples/family, group, psychiatry/medication management, other (be specific)
Do you currently use an EHR or Billing system? If so, which one?
What's your biggest challenge with billing right now?
YesNo
Thank you!

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