New Client Submission Form
Thank you for your interest in our services. Please complete the form below to get started. Someone from our team will reach out to you to follow-up.
Sign in to Google to save your progress. Learn more
Email *
Name *
Phone number
 *
Date of Birth:
 *
MM
/
DD
/
YYYY
Please tell us a little bit about what you are looking for support with:
 *
What state are you located in?
 *
Which service are you interested in?
 *
Required
Therapy Needs *
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:
 *
If you are planning to use insurance for sessions, what type of insurance do you have? (Accepted insurance plans are listed below.)
 *
Please enter the Member ID from your insurance card (this allows us to verify benefits for services and is required in order to be added to waitlist):
 *
Please enter the Group Number from your insurance card:
 *
Are you currently experiencing any of the following:*
***IMPORTANT NOTE*** This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 988 or visit your local emergency room.
 *
Required
If you endorsed any of the above, please describe here. If you checked "none of the above" simply write n/a here.
 *
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.) ?
 *
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 when we have an opening that meets your needs.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Mhoodle. Report Abuse
Google Forms