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New Client Inquiry Form
Hi there! I am excited for us to begin our work together. Please complete this form so I can get a better understanding of what you need. This information will not be shared with anyone outside of Innerbloom Psychotherapy, PLLC.
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First and Last Name
*
Your answer
Parent/Guardian First and Last Name (For minor clients)
Your answer
Preferred Pronouns
She/Her/Hers
He/Him/His
They/Them
Other:
Clear selection
Date of birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email
*
Your answer
What are you requesting at this time?
*
Consultation
Scheduling an intake
Other:
Preferred method of contact
*
Email
Phone
Text
What days work best for you for a consultation?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Required
What times work best for you for a consultation?
*
Morning
Afternoon
Evenings
Required
Are you a Texas resident?
*
Yes
No
Other:
If you feel comfortable, briefly tell me what you would like to work on.
Your answer
How would you like to meet for services? Please note there are limited in person slots available.
*
Telehealth
In-person in Austin, Texas
Both
What best describes your payment method?
*
Insurance
Private Pay with superbill
Private Pay, no superbill needed
Requesting sliding scale
If utilizing insurance, please select your health plan.
Aetna
Cigna
Oscar
Oxford
United
Other:
Clear selection
If you are requesting sliding scale, tell me a little bit about your situation.
Your answer
How did you find Innerbloom Psychotherapy? If you were referred by another therapist/provider, please list their name.
Your answer
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