Second Story Counseling New Client Form

1
Your Name* This field is required.
First Name
Last Name
2
utm_source
3
utm_campaign
4
utm_medium
5
gclid
6
Contact Phone* This field is required.
Please enter a valid phone number.
7
Contact Email* This field is required.
example@example.com
8
Who is this appointment for?* This field is required.
Me
Someone Else
9
Patient's Name* This field is required.
First Name
Last Name
10
Is {patientsName} a minor?* This field is required.
YESNO
11
Do you plan on paying with insurance?* This field is required.At this time, we accept BlueCross/BlueShield and Aetna Insurances
YESNO
12
Which Insurance Provider do you have?* This field is required.
Aetna
BlueCross/BlueShield
13
Take a Photos of the FRONT of Your Insurance Card* This field is required.
14
Take a Photos of the BACK of Your Insurance Card* This field is required.
15
Schedule Your Consultation Time* This field is required.Our receptionist will call/email you within 24 hours to confirm your appointment time and insurance info (if applicable). Then, at the time of your appointment one of our therapists will give you a call.
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Anything else you want us to know about you (or the client) before the initial consultation?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: