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NAT20Therapy: Interest Form
Hi there!
Thank you for choosing Nat 20 Therapy!
Unfortunately, we have a waitlist for new individual clients at this time. Please complete the form below with your goals for therapy, and we will be in touch as soon as we have an opening.
For a more timely service provision, we highly recommend using
www.psychologytoday.com
as it will support you in your search for a therapist. Please also feel free to e-mail us at
info@nat20therapy.com
for a list of referrals and resources based upon your needs.
For folks interested in our group, please complete the form below and we will be in touch to schedule a time for you to connect with Charlene to learn more about our next available group.
We look forward to supporting you in the future,
The Nat 20 Therapy Team
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* Indicates required question
First & Last Name (Preferred Name)
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
If seeking therapy for your child, insert your Child's Full Name here:
Your answer
Client's Date of Birth
*
MM
/
DD
/
YYYY
Pronouns
*
Your answer
Are you interested in group or individual therapy or both? I highly recommend both in order to get the most out of the program.
*
Group
Individual
Both
Have you or your child ever been in group or individual therapy before?
Group
Individual
Other:
Are you interested in In-person or Telehealth?
*
In-Person
Telehealth
No Preference
Please indicate your or your child's availability for sessions.
Morning (9am-11am)
Afternoon (12pm-4pm)
Evening (5pm-7pm)
How familiar are you or your child with the game Dungeons and Dragons? *No experience necessary*
Never Played
Played for 1 year
Played for 3-5 years
Clear selection
If you or your child have experience playing Dungeons and Dragons, what type of character would you or your child be interested in playing?
Your answer
Groups are 5 people each. Would you or your child feel comfortable joining a group with 5 members?
Yes
Maybe
No
N/A - individual only
Clear selection
What days would you or your child be available for group? Each group lasts for 90 min, occurs once a week, for a six week session.
Monday
Tuesday
Wednesday
Thursday
Friday
Other:
What month would you or your child be able to start?
January
February
March
April
May
June
July
August
September
October
November
December
Please note that our practice is out of network with all insurance plans and does not accept insurance. More information on our rates for individual and group therapy can be found here:
https://www.nat20therapy.com/investment
We have partnered with
Reimbursify
for you to easily submit your claims for out-of-network health insurance reimbursement. Download the app and get your first five claims for this practice at no cost.
I understand that insurance is not accepted and and have reviewed the insurance policy and Cost of Therapy. Invoices will be provided to me after payment, which I can submit to my insurance provider for possible reimbursement for the cost of my therapy session.
How did you hear about us? Examples: Physician, School, Therapist, social media, former/current client.
Choose
Psychology Today
Referral (Current Therapist, Pediatrics, etc.)
Google
YouTube
Social Media
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