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 are your preferred pronouns?
  • Format: (000) 000-0000.
  • What is your date of birth?*
     - -
  • How did you hear about us?*
  • Which directory?
  • Had you heard about us before today?
  • Which platform?
  • Where did you see the ad?
  • Which event?
  • Do you have a preferred provider?*
  • What type of treatment are you seeking?*
  • We offer services both in person, and virtually via Telehealth. Which modality do you prefer?*
  • Which insurance provider will you be using, or will you be paying privately?*

  • 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)
  • Should be Empty: