New Client Inquiry Form

New Client Inquiry Form

We invite you to complete this short, HIPAA-compliant and encrypted form. Once submitted, we’ll connect with you to schedule your consultation and begin your care journey. If you are completing this form on behalf of someone else (such as your child), please make sure to provide their information so we can best support their care.
What is your preferred name?*

First NameLast Name
What is your legal name (if different from your preferred name)

First NameLast Name
What are your preferred pronouns?

They/ThemShe/HerHe/HimOther
What is your email?*
example@example.com
What's the best phone number to contact you at?*
Please enter a valid phone number.
What is your date of birth?*

MonthDayYear
Date

What is your mailing address?*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*

Professional referral (Referred by another healthcare/mental-health provider)Client / word-of-mouth (Referred by a friend, family member, or current/past client)Online search (Found via online search (Google, Bing, DuckDuckGo, etc.)Online directories (Psychology Today, ZenCare, WellConnected, etc)Social media (Instagram, Facebook, TikTok, LinkedIn, etc.)Advertising (Saw an ad (Google Ads, Facebook/IG, podcast, print, etc.)Event / workshop (Attended one of our classes, breathwork sessions, or community events)Insurance directory (Insurance provider website/app)Other
Who referred you?
We'd love to say thank you 🥰

A Note About This Next Question

You’ll see a question next on our form asking for your sex assigned at birth. We recognize this can be uncomfortable, invalidating, or triggering, especially for trans and gender-expansive people who have already done the work of changing their documents and living as their true selves. Unfortunately, most insurance companies still use sex assigned at birth to make decisions about what services, labs, and medications they will cover. To reduce the chance of your claims being denied, we’re required by insurance companies to collect this information and share it with your insurer when we bill them. If you are not using insurance, we will not ask for this information. Inside our clinic, we will always use your affirmed name, pronouns, and gender identity. This question is about navigating an imperfect insurance system, not about how we see you or who you are. If you have feelings or concerns about this, you’re very welcome to talk with your provider about it.
What sex were you assigned at birth? (required because you selected you'll be using insurance)

FemaleMaleIntersex

Any specific scheduling needs?
Is there a specific time and day that you're ideally looking for?
What feels most important for you to focus on with a provider?
This information will be used to match you with a provider that fits your needs
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