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New Client Information
Thank you for selecting For Us Therapeutics for your mental health services. Please fill out our brief survey and give 24 hours to respond. We are looking forward to working with you.
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Today's Date:
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Name ( First and Last)
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Email
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Address
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Phone number
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What is bringing you in for therapy at this time?
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Your answer
What kind of therapy are you seeking?
Individual Therapy
Couples Therapy
Group Therapy
Family Therapy
Other:
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Which Therapist are you interested in working with?
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Brian Sutton
Philip Sain
Erica Doe
LaKeith Sutton
Renee Bullock
Jemila Meekins
Tawana Lee
No Preference
Other:
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Would you like to do in person Therapy or Telehealth?
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In-person therapy
Telehealth
What Insurance do you have?
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BlueCross BlueShield
United Healthcare
Cigna
Aetna
Maryland Medicaid
Out of Pocket
EAP
Other
Other:
Best Days and Times to meet?
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