Therapy Inquiry
You have taken the first step in your journey toward wellness!  We are here to help.  This is what you will need to proceed - please have this all together to proceed with establishing services:
  • Valid Picture of Drivers License or State ID of the person or guardian requesting services
  • Valid Picture of Insurance card - front and back
  • Custody Paperwork/Guardianship/Parenting Plan Paperwork/Power of Attorney (if applicable, this IS required)
  • Demographic Information (home address, phone number, email, date of birth of client)
  ***WE NEED A NEW THERAPY INQUIRY FORM FOR EACH PATIENT AND DATE OF SERVICE***
Email *
Please tell us your name: *
Phone Number: *
Email Address: *
Do you prefer text or phone call? *
What is the best time to reach you by phone or text? *
Required
Who are you requesting services for: *
Required
Legal name of new patient (please fill out inquiry form for each new patient) *
DOB of new patient *
MM
/
DD
/
YYYY
Postal address of new patient *
Preference for counseling (click as many as applicable) *
Required
How did you hear about us? *
Were you referred by a School District? *
If you were referred by a school district, which one?
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What would you like us to know about you or the person you are referring, initially?
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