Initial Request

Understanding Insurance
Do you have a secondary or supplemental health insurance plan? (Not including dental or vision insurance). If yes, what is the secondary?
Are you aware of your coverage and know your copays and/or deductibles?*

YesNoI have no idea
Before scheduling, we verify your insurance coverage so you’ll know in advance what charges (if any) to expect (this is optional). To speed up the process, you can enter your insurance card number below. You can also phone or text our office staff (319)853-8762. Enter insurance card # below.

Services We Do Not Provide
There are some services we do not provide, including writing letters for support animals, testifying in lawsuits, diagnosing for lawsuits, or conducting therapy for the sole purpose of supporting a disability claim. Are you seeking help for any of the above issues?*

YesNo
What kind of help are you seeking? Do you have another provider who could provide this service?*

Previous Therapy
Have you ever had psychotherapy (Talk Therapy)*

YesNo
Are you currently receiving psychotherapy at another practice? If so, what type of therapy are you getting? (individuals, couples, family)*

Treatment Options
What kind of therapy are you looking for? (check all that apply)*

I am 18 years or older wanting therapy for myselfI am a parent looking for therapy for my childI am 18 years or older looking for couples or relationship therapyI am 18 years or older trying to help someone else find a therapistI am a teen or child looking for therapy for myself

Adult Individual Therapy
Please describe the challenges you are currently experiencing.*
Have you ever been in a hospital or residential setting for mental treatment?*

YesNo
Briefly describe the type of treatment you received (e.g., hospital, residential, outpatient, etc.) when it took place, and approximately how long it lasted?*
What was the reason for your treatment? How are you doing currently?*

Helping Someone Else Find a Therapist
What is the problem of the person you are helping?*
Does the person you are helping know you are contacting therapists on their behalf?*

YesNo
What is your relationship to the person you are trying to help?*

I am with an agency, insurance company, or EAPI am a family member or friendI am a therapist or provider looking to refer a clientOther

Therapy Request by Teen
Please tell us what challenges you are experiencing?*
Is it OK if we contact your parent or legal guardian?*

YesNo
What is the name of your parent/guardian? It has to be your legal guardian, which is usually a parent.*
What is your parent/guardian's phone and/or email?

Submit Form

Click the submit button below. We will have one of our therapists look over your responses and our office staff will get back to you about your appointment. Thank you for completing this form.
Type a question
Should be Empty:

Do you have insurance?