Appointment Request Form
Please fill out the information below and our Client Care Coordinator will reach out to you with scheduling options. This is a secure form that will only be viewed by our intake team. 
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Name of person completing this form: *
What is your relationship to the client who will be receiving services? *
Last name of client: *
First name of client: *
Client's pronouns and preferred name if different from above *
Client's date of birth: *
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Phone number: *
Email address: *
How did you hear about us? *
Is there a certain therapist you are interested in working with? Check all that apply.

Learn more about our therapists here.
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Availability
Please list your preferred availability as best you can
Monday *
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Tuesday *
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Wednesday *
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Thursday *
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Friday *
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Saturday *
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Sunday *
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Please provide any additional information about scheduling that you feel would be helpful. You can also indicate your top three days and times if you'd like.
Are virtual or in-person sessions preferred? *
Insurance and Billing
Realistic Serenity is an in-network provider for most major insurance companies. We will do our best to verify your insurance and provide you with an overview of your benefits and an estimate for your financial responsibilities. Please answer the following with N/A if you are not wanting to use your insurance.
Insurance Carrier *
Member ID *
Group ID *
Name of Policy Holder *
If we are not able to match your with a therapist right away, would you like to be added to our waitlist? *
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