Congratulations on taking the first step to Envision Your Mental Health Journey
Please take a moment to fill out the form below, allowing us to gather additional information about the purpose of your therapy request. This information is crucial for both beginning the registration process and confirming your eligibility for insurance coverage, should you be utilizing insurance. Once we receive your request, our dedicated Client Care Coordinator will reach out to you with the necessary next steps. Call 911 or go to the nearest emergency room if you or someone you know is experiencing a crisis. Your safety and well-being are of utmost importance.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please specify your therapy location
*
Please Select
New York
Georgia
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In the past 60 days, have you been in any inpatient or outpatient treatment program?
*
Please Select
Yes
No
Are you required by the court or CPS to participate in therapy?
*
Please Select
Yes
No
Have you had any thoughts of harming yourself or others?
*
Please Select
Yes
No
Have you ever attempted suicide or engaged in self-harm?
*
Please Select
Yes
No
Are there any current safety concerns (violence, abuse, neglect)?
*
Please Select
Yes
No
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Next
What services are you looking for?
*
Please Select
Individual Therapy
Adolescent/Teen Therapy (13-19)
Child Therapy (6-12)
Couples or Marriage Therapy
Group Therapy
Please choose at least one day
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please enter time that works between 9:00am-7:00pm for your weekly therapy appointment
*
What brings you to therapy at this time? What are your main concerns or goals for treatment? How long have you been experiencing these concerns?
*
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Next
Please select your primary insurance from the list.
*
Please Select
Aetna
Cigna+ Evernorth
Healthfirst
Oxford Health Plans
Oscar Health
United Healthcare
Blue Cross and Blue Shield
Anthem Blue Cross and Blue Shield New York (formerly Empire)
Open Path Collective Client
New York Medicaid
Cash Pay (paying out of pocket)
Enter your primary insurance member ID or "N/A" if not using insurance.
*
Enter your primary insurance group number or "N/A" if not using insurance/don't have one
*
Please upload a picture of the front of your insurance card (If you are not using insurance, you can upload your drivers ID or any state ID).
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a secondary or another insurance policy?
*
Please Select
Yes
No
Please select your Secondary insurance from the list.
Please Select
Aetna
Cigna+ Evernorth
Healthfirst
Oxford Health Plans
Oscar Health
United Healthcare
Blue Cross and Blue Shield
Anthem Blue Cross and Blue Shield New York (formerly Empire)
Open Path Collective Client
New York Medicaid
Cash Pay (paying out of pocket)
Enter your secondary insurance member ID.
Consent & Practice Polices
*
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THE INFORMED CONSENT & PRACTICE POLICES.
*
Please tell us how you heard about us
*
Alma
Doctor's Office/Medical Office/Hospital
Facebook
Google Search
Headway
Instagram
Referral
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