Contact Form

Welcome to Quiet Contemplation

New Client Information
What name do you go by?

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Best number to reach you
E-mail
For appointment updates and helpful resources
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (please share someone we can reach in case of emergency)

First NameLast Name
Emergency Contact Phone Number
What brings you here today?
Please choose the type of support you’re interested in:
Note: 1:1 therapy is available in FL, SC, and MN
Insurance Information

If you plan to use insurance, this helps us prepare before your first session.
What type of insurance coverage do you have?

No insurance / self-payPrivate health insurance (e.g. BCBS, UHC, Aetna)Medicaid / state-based insuranceOther (please specify)
Insurance Provider Name
Example: Blue Cross Blue Shield
Authorization & Consent

Consent and Acknowledgment
By submitting this form, I confirm the information I’ve shared is accurate and complete. I understand that Quiet Contemplation will use this information to support scheduling and communication. My information will not be shared outside Quiet Contemplation without my permission.

I understand that submitting this form is for intake and scheduling purposes only and does not create a therapist-client relationship. Therapy services begin only after consent is completed and services are confirmed.

If I am experiencing a mental health emergency, I understand that this form is not monitored in real time and I should contact local emergency services or a crisis hotline (211)
Signature

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Thank you for taking the time to complete this form.
Once you click submit, our team will review your information and reach out within 48 business hours.

If you need support sooner or have questions in the meantime, you are welcome to text our support line at 727-379-2248 to connect with Ashley, our Operations Manager. We are so glad you are here.
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Welcome to Quiet Contemplation

What brings you here today?

Insurance Information

Authorization & Consent