A Path to Wellness | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Contact Number

Email Address

Reason for care

Please share a brief overview of your current situation.

Limited to 600 characters

What kind of care is being sought?

Individual Psychotherapy (General Mental Health - Anxiety, Grief, Depression, etc) Individual Sex Therapy Couples Sex Therapy Relationship Therapy/Marriage Counseling Discernment Counseling Divorce Counseling

Administrative

Inquiry reason

How did you learn about us?

Enter how you were referred to our services

If a healthcare provider sent you our way, please tell us who they are, so we know who to thank to (and maybe have coffee with them)

Name of the Provider/Practice

Billing & Payment

Payment method

How do you plan to pay?

Insurance details (Skip this part if you selected Self-Pay)

For individual session, provide insurance details for verification of benefits (Name of insurance, Member ID & DOB) **Couples/Marriage Counseling is not covered. **We don't accept Medicaid

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

When Would You Like Us to Call?

Please specify the date and time you prefer for our Practice Manager to contact you.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.