New Client Appointment Request
We appreciate your interest in becoming a client at the Center for Transformative Healing. Please take a few moments to help us learn more about what services you are seeking. The information gathered on this form will be used to assess if our services may be a good fit for you and to match you with one of our therapists.  We will contact you within 2-3 business days after the form is submitted.
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Are you seeking services for yourself or on behalf of another person? *
If you are filling this form on behalf of another person,  please provide YOUR NAME, YOUR RELATIONSHIP to the prospective client and  YOUR EMAIL ADDRESS or phone number. 

*Please note if you are inquiring about couples therapy please include BOTH partners name, date of birth, email address, and phone number. 
Required
Prospective Client(s) First  & Last Name(s) *
Date(s) of Birth *
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Prospective Client(s) Email Address(es) *
Phone Number(s) *
What is your preferred method of being contacted? *
Required
How did you hear about the Center for Transformative Healing?
Please check all that apply.
In what (s) state will you be residing while receiving our therapy services? *
Please specify state of residency or where you plan to be located while participating in our counseling services.
How are you hoping to pay for services?   ****Please note that our center is only contracted with PacificSource (OHP & Commercial plans), some Aetna plans, and Providence.                                        
If you plan to use insurance, please provide the name of the insurance and ALL of the following information below:
1) Name of Insurance
2) Subscriber Name & DOB
3) Subscriber Address
4) Subscriber ID # and Group #
5) Phone number on back of card to check benefits. 

**If you have insurance that CTH contracts with, then center admin will verify benefits for you.                          
What services are you currently seeking? *
Required
Reason For Seeking Services *
Please provide a brief description about what brings you to therapy at this time in your life:
Have you been to therapy before? If so, briefly describe any particular aspects that you found more or less helpful.
Do you currently struggle or have you struggled with any of the following concerns: self-injurious behavior, compulsive sexual and unsafe sexually related behaviors, severe substance misuse, or chronic suicidality? If yes, please specify what you have struggled with and at what point in your life. *
If you are suicidal please go your nearest emergency room, call 911,  or contact  the  national suicide lifeline at 800-273-8255:
Have you ever been hospitalized for mental health reasons? *
This includes residential treatment for mental health or substance abuse.
What is your availability for appointments? Specific days/times that are preferred? *
Please indicate if you have a preferred therapist(s) to work with at the Center for Transformative Healing. *
How would you like to receive our psychotherapy services: *
Demographic Information: The following questions about Gender Identity, Race/Ethnicity, and Sexual Orientation are completely OPTIONAL. We gather this information because some of our clinicians specialize working with certain identities and this information helps us to match you with the right therapist (please refer to the clinician's individual bio's to learn more).
Please let us know if you or a person likely to join you for therapy need services delivered in a language other than English? *** We currently only have providers that can offer services in English and Mandarin.
Racial & Ethnic Background
Gender Identity & Pronouns
Sexual Orientation
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