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New Client Scheduling
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* Indicates required question
First name of client
*
Your answer
Last name of client
*
Your answer
Preferred Name
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Cell phone number
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Email
*
Your answer
Parent/Caregiver 1 Full Name
(required for minors)
*
Your answer
Parent 1 Email
(required for minors)
*
Your answer
Parent/Caregiver 2 Full Name
(required for minors)
*
Your answer
Parent 2 Email
(required for minors)
*
Your answer
Who is responsible for payments?
(We do not allow split payments.)
*
Your answer
If the client is a minor, do you have full legal custody?
Yes
No
Clear selection
If you share legal custody we must get informed consent from the other parent. Please provide the name, email, and phone number of the other responsible party.
Your answer
Type of Service
*
Choose
Music Therapy
Art Therapy
Outpatient Counseling
Play Therapy
Expressive Arts Group Therapy
Therapist Preference
(We will do our best to match you with a therapist of your preference, as available.)
*
No preference
Lawson (play therapy, counseling)
Sarah (play therapy, counseling)
Jillian (art therapy, counseling)
Hayley (art therapy, counseling)
Natalie (art therapy, counseling)
Alyssa (art therapy, counseling)
Anna (music therapy, EMDR)
Raven (music therapy)
Christina (music therapy)
Daneyelle (music therapy)
Chris (music therapy)
Erin (music therapy)
Required
Reason for seeking services
*
Your answer
Payment Method
(
Please note that Music Therapy is not funded through private insurance or Medicaid.)
*
In Network Insurance Benefits - for Counseling, Art Therapy, or Play Therapy only
Medicaid - for Counseling, Art Therapy, or Play Therapy only
CSA Funding
Cash/Card Pay
Insurance Carrier (if applicable)
Your answer
Medicaid MCO (if applicable)
Your answer
Additional Information
Your answer
How did you hear about us?
*
Your answer
Would you like to subscribe to our weekly email newsletter to stay up to date on resources, services, and therapist openings?
*
Yes
No
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