New Client Form

New Client Form

Please fill out the following questions so we can better assist you in finding the therapist that is right for you. Thank you for your time!
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your insurance*
OPTIONAL: Please provide of copy of the front and back of your insurance card
Copy of front of Insurance Card

Cancelof
Copy of back of Insurance Card

Cancelof
Are you looking for Telehealth or In-Person?*

TelehealthIn-PersonBOTH
What location are you interested in?*

Council Bluffs, IAFremont, NEOmaha, NE
What is your availibility?*

First AvailableMorningsAfternoonsLate afternoon to evening
What is the reason you are wanting services?*
What is the best way to reach you?*

EmailPhone
Are you interested in a specific therapist? If so, please list their name below:
I would like to subscribe to The Cord's newsletter:*

YESNO
The Cord will contact you with any additional questions or information that may be needed.
Should be Empty: