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Client Name

First

Last

Date Of Birth (Of Client)

Parent or Guardian Name (If Applicable)

First

Last

Phone

Insurance Provider

Subscriber's Date of Birth

Contract ID Number

If you have your insurance ID number, please include that here. This helps us be more efficient.

Upload a picture of your insurance card (if available)

Drag & Drop Files, Choose Files to Upload

Location Of Phone

Relationship to Client

(If a minor)

Tell us a little about how we can help

Type of Therapy

If prospective client is a minor, is there shared legal custody between Parents/Guardians?

Our policy is that anyone with shared custody of a minor consents for services.

Other helpful information

(Faith preference, Multiple homes, Clinician gender preference, Languages spoken in the home)

How did you hear about us?

Individuals