BA Healing: New Client Submission Form

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Thank you for your interest in scheduling an appointment with our team.

We have appointments available immediately with most of our team members and we are eager to connect you with one of our staff.

Please complete the form below and we will contact you within 2-3 business days with an available intake appointment date and time.

If the clinician you'd like to work with does not have space in their schedule to meet with you, you'll be notified and automatically added to our waitlist. We will offer a referral to another clinician on our team if available and you can choose whether to remain on the waiting list or to accept the alternate appointment.

If you're placed on the waiting list, someone from our team will contact you by e-mail and phone when we have an opening with the best provider for you!

Please note: forms submitted with incomplete information are not able to be added to our waitlist.

*If you're in crisis please do not submit a request through this form, as we may not see it in a timely manner. Please contact your local crisis center, call 988 (Suicide Lifeline) or 911 (police/rescue) or go to your nearest emergency room if you need immediate help.

Email *

Name
*

Phone number
*

What is your E-mail Address?
*

Who are you seeking therapy services for? *

Myself

My Child

Other (Family, Group, etc)

Child's Name and Age - if You're Requesting an Appointment for a Child

If you are requesting an appointment for a child, please confirm the following: *

I have full custody and have court documentation

I share custody, have court documentation and the other parent agrees to therapy

Parents are partnered and agree to therapy

Not Applicable

What are your or your child's pronouns? (she/her, they/them, he/him, etc.) *

You or Your Child's Date of birth
*

YYYY

Are you looking for individual or group therapy? *

Individual Therapy

Group Therapy

Other:

Required

Please tell us a little bit about what you are looking for support with:
*

What type of therapy are you interested in?

Talk therapy

Somatic therapy

Trauma Therapy

Group Therapy

EMDR

Brainspotting

Other:

Do you prefer to meet in person or virtually? *

In person

Virtually

Either

What state are you located in?
*

Tell us a little bit about what works best for you as far as a provider's interaction style (i.e. I'd I prefer to work with someone who is direct, offers feedback, is compassionate, nurturing, etc.) You can reference what you have liked or not liked about working with providers in the past if applicable:
*

What identity characteristics are important to you in your therapist? For example, would you prefer a clinician who identifies as BIPOC? Do you have a gender preference in your therapist?

Is there a specific provider you are interested in working with? (Please note: not all of our clinicians currently have openings, however this information is helpful to us in understanding what you are looking for in a provider and we will work to offer you the closest match possible)
*

Laura Reagan

Edwin Hernandez-Martinez

Ilana Posner

Tanory Ateek

Victoria Marinzel

No Preference

Required

How Did You Hear About BA Healing? *

Our practice is an out of network provider and does not accept insurance. Our Rates per session range from $175 - $250 for the first session, and $150 - $335 per session for follow up sessions. We can provide documentation of sessions to submit to your insurance company or Flexible Spending Account/Healthcare Savings Account administrator for partial or full reimbursement depending on your benefits.

While we do provide documentation to assist, we are not responsible for determining your eligibility for reimbursement. If you are unsure about your benefits or our fees please visit the Fees/Insurance section of BA Healing's website for additional information: https://bahealing.com/fees .

I understand the insurance policy and Rates per session and would like to move forward with scheduling

I need more information

Are there any specific scheduling needs we should consider when setting up your appointment time (i.e. mornings before 12pm, specific days of the week, etc.) ?
*

Here's What Happens Next!

Within 2-3 business days, you will receive an email matching you with a potential provider.

If the appointment time offered works for you, we ask that you confirm your appointment by 5pm the next business day.

Once your appointment is confirmed, you will be introduced to your therapist where you can schedule a 15-minute phone consultation to ask any questions you may have and see if it feels like a good fit prior to your intake appointment.

You will also receive an email with your intake paperwork attached. We ask that this intake paperwork be completed at least 48 hours ahead of your first appointment to give your therapist enough time to prepare for session.

Any questions? *

Thank you so much for this important information, as it helps us better determine the right match for you in working with one of our providers! We will reach out to you within 2-3 business days to offer an appointment or let you know that you've been added to our waiting list.

A copy of your responses will be emailed to the address you provided.

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