Broadhollow Get Started Form

Client Name* This field is required.

First Name

Last Name

Preferred Name(optional)

First name

Person Filling Out This Form (skip if client)

First Name

Last Name

Relationship to client(Only parents of minor children can act on their child's behalf. Please no spouses or parents of individuals 18 years old or older)

Email* This field is required.

example@example.com

Phone Number* This field is required.

Address* This field is required.(Must be address associated with insurance plan)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Date of Birth* This field is required.

Date

Gender* This field is required.scroll down for all options

Marital Statusscroll down for all options

💡 Important Note
Broadhollow Psychotherapy provides therapy services only.
We do not prescribe medication or offer psychiatric services.

What challenges or concerns are showing up for you at this time? Please check all that apply.* This field is required.scroll down for all options

Anxiety, worry, or panic concerns

Depression, sadness or hopelessness

Childhood Trauma

PTSD Symptoms

Grief or Loss

Relationship/Couples issues

Family conflict

Work-related stress or burnout

Difficulty focusing or ADHD

Sleep problems

Anger or irritability

Low self-esteem or self-worth

Identity exploration (racial, cultural, sexual, gender)

Life transitions (divorce, relocation, career change)

Parenting challenges

Substance use or addiction concerns

Physical health issues impacting mental health

Feeling “stuck” or overwhelmed

Executive Dysfunctional

Memory issues

Hallucinations or delusional thoughts

Victim of a crime

Self-harming behaviors

Suicidal ideation

Other

⚠️ SAFETY NOTE

If you are thinking about suicide or feeling like you’re in immediate danger, please do not wait for an appointment with us to speak to someone about those feelings.

👉 Call 911 or go to your nearest emergency room.
👉 You can also call or text 988 for the Suicide & Crisis Lifeline (24/7)

Are you currently taking any medication for mood, anxiety, focus, sleep, or other mental health concerns?* This field is required.

YESNO

Will you be using your insurance* This field is required.

YESNO

💡 ABOUT SELF-PAY

If you’re not using insurance, we’d be glad to work with you on a self-pay basis.

Our standard fees are:

Initial evaluation (first session): $225

Ongoing individual therapy sessions: $135

Please note: fees for couples therapy, EMDR intensives, Reiki, and other specialty services are different and will be discussed with you before scheduling.

Primary Insurance* This field is required.Plans we do NOT accept: GHI, Community Plan, Magnacare, Medicaid, Molina

Primary insurance ID number* This field is required.

Secondary Insurance* This field is required.Plans we do NOT accept: GHI, Community Plan, Magnacare, Medicaid, Molina

Secondary insurance ID number* This field is required.

File Upload* This field is required.Please upload a clear photo or scan of the FRONT of your insurance card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

File Upload* This field is required.Please upload a clear photo or scan of the BACK of your insurance card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

File Upload* This field is required.Please upload a clear photo or scan of the VALID ID of client or parent (IF APPLICABLE)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Do you have a preference for therapist?* This field is required.We strive to honor preferences whenever possible. Please note that choosing a specific therapist may result in longer wait times, and we cannot guarantee their availability. We’ll work hard to match you with your preferred therapist, if possible, but scheduling limitations may apply.

Would you like to be seen VIRTUALLY or In Person?* This field is required.

What days and times are you GENERALLY available for therapy sessions?* This field is required.Please note: Completing this form does not book an appointment. Let us know your general availability. The more options you provide, the easier (and quicker) it is for us to match you with a therapist. Lunchtime sessions are often fast to book. Evening appointments are available but in high demand, and weekend appointments are extremely limited.

Ex. Mondays, Tuesdays after 3pm

Step 1 is complete!

Now, what’s NEXT??

Step 2 Insurance Check (24–48 business hours)
If you’re using insurance, our team will verify your coverage. (Heads up: weekends and holidays don’t count toward the clock ⏰).

Step 3 Patient Portal Invite
Once verification is done, you’ll get an email invite to our secure patient portal. That’s where you’ll complete intake forms, assessments, and consents.

Step 4 Therapist Assignment
When your portal is complete, we will inform you once you've been paired with a therapist and they will reach out to you to schedule your intake appointment.

Broadhollow Get Started Form