New Client Appointment Request
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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.
Required
Prospective Client(s) First  & Last Name(s) *
Date(s) of Birth *
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Prospective Client(s) Email Address(es) *
Phone Number *
What is your preferred method of being contacted? *
Required
How did you hear about Aguirre Center for Inclusive Psychotherapy?
Internet search,  Google Ads,  Online Directories (Latinx Therapy, Psychology Today, Therapy Den, Inclusive Therapists, etc). Social Media (Instagram, Facebook, etc)  or were you referred by another professional?
In what (s) state will you be residing while receiving our psychological services? *
 Please specify state of residency or where you plan to be located while participating in our counseling or testing services.
What services are you currently seeking? *
Required
Reason For Seeking Services *
Please provide a brief description about the concerns you wish to address:
How would you like to receive psychological services from ACIP: *
What is your budget per individual/couples session (sessions are scheduled weekly or biweekly):  *
As a reminder, ACIP does NOT accept insurance nor  works with EAP programs.*  Clients are expected to pay for their services at the time of service with a credit/debit card, HSA/FSA card,  or check and we  provide clients superbills for potential insurance reimbursement.  *The sole exception is for Dr. Sophia Aguirre is in-network with Pacific Source and will bill claims on your behalf only for Pacific Source.
Required
Please indicate if you have a preferred therapist(s) to work with:
What is your availability for appointments? Specific days/times that are preferred? *
Do you currently struggle or have struggled with any of the following concerns: self-injurious behavior, compulsive sexual behaviors or pornography addiction, an eating disorder, or chronic suicidality? *
If you are suicidal please go your nearest emergency room, call 911,  or contact  the  Georgia Crisis Line (800-714-4225) or the Crisis Text Line (text "START" to 741741).
Have you ever been hospitalized or received residential treatment for mental health  or substance abuse concerns? *
If yes, please list dates of treatment and focus of treatment.
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 gender or race and this information helps us to match you with the right therapist (please refer to the clinician's individual bio's to learn more).
Racial & Ethnic Background
Gender Identity & Pronouns
Sexual Orientation/Sexual Identity
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