New Client Appointment Request

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The information gathered below will help me determine if my services may be a good fit for your needs. You will hear back from me promptly to schedule an Initial Assessment appointment, or will be provided referrals if I am not able to meet your needs. Due to the high demand for my services, it may take up to 2 business days. If you have not received a response within 48 business hours, please give me a call.

If you are not seeking services for yourself, and 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. *

I am the person seeking services and filling this from out for myself.

Other:

Required

Prospective Client(s) First & Last Name(s) *

Prospective Client(s) Date(s) of Birth *

YYYY

Prospective Client(s) Email Address(es) *

Phone Number(s) *

What is your preferred method of being contacted? *

Text Message

Phone

Required

How did you hear about our services?

Google search, LatinxTherapy, Psychology Today, Instagram, Yelp, were you referred by another professional, etc.?

In what (s) state will you be residing while receiving our psychological services? *

Please specify in which state(s) you plan to be located while participating in therapy sessions.

Dr. Sophia Aguirre does not directly bill insurance and is considered an Out of Network provider*. We offer superbill receipts for clients with out-of-network benefits who wish to file for reimbursement on their own. Clients pay for their services at the time of service with a credit card, debit card, or HSA/FSA card. Please confirm that you understand our billing policies. *

*Dr. Aguirre is an in-network provider for Pacific Source Health Plans only and will bill Pacific.

I understand all services are private pay and am prepared to pay out of pocket.

I am currently insured by Pacific Source Health Plans and am prepared to pay my copay.

Other:

Which services are you currently seeking? *

We are not in-network nor do we bill with any health insurance plans except for PacificSource; we do offer superbills (receipts that you can submit for reimbursement) for people with out-of-network benefits.

Individual Therapy

Couples/Relational Therapy

Group Therapy

Psychological Testing/Assessment (for ADHD/LD Evals, etc).

Other:

Required

Reason For Seeking Services *

Please provide a brief description about the concerns you wish to address.

Do you currently struggle or have struggled with any of the following concerns: self-injurious behavior, compulsive sexual behaviors or porn 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).

Other:

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.

Other:

What is your availability for appointments? Specific days/times that are preferred? *

How do you prefer to receive services? *

In person services (in Dr. Aguirre's office in Atlanta)

Telehealth services (online/video sessions)

I don't have a preference.

Other:

If Dr. Sophia Aguirre has a long wait for services, would you be interested in the possibility of working with another therapist at the Aguirre Center for Inclusive Psychotherapy? *

You can view a list of the therapists at Aguirre Center here: https://www.inclusivepsych.com/therapists

Yes

Other:

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