Therapies Request Form

1

Please share some information about yourself so we can get you connected to the right provider.

2

First name

3

Last name

4

Phone number

Please enter a valid phone number

5

Email

example@example.com

6

Date of Birth

Date

7

Which service(s) are you interested in?

Blood Work, Lab Testing & Diagnostics (virtual)

Integrative Psychiatry (virtual)

Psychotherapy (virtual)

Coaching (virtual)

Physical Therapy & Performance Training (virtual/in-home)

8

Do you plan to use insurance to help pay for your services?* This field is required.Insurance is complicated- some services at Elsewhere may be covered, others might not. We are in network with some but not all the local & national carriers. Additionally we accept private pay, HSA and FSA.

YESNO

9

Insurance carrier:

10

What brings you to Elsewhere, and what are you hoping to work on?

11

Provider preferences:(e.g. Specific provider you're interested in? Gender? Specialty? Style or approach? Personality traits? Communication style? etc.)

12

Availability:When are you generally available to meet, and are there any times that are completely off the table?

13

Next, we will reach out to you directly to prepare for your first appointment. What is your preferred method of communication?

Phone

Text

E-mail

Any is fine