New Client Inquiry
Welcome!  

*My schedule is very limited at this time but you are welcome to fill out the questionnaire if you would like to be contacted for openings. You may also check my Instagram page for opening announcements @wvtraumatherapist. Thanks!

Please take a moment to complete this short questionnaire. This will provide preliminary information to get started and also to help assess the most effective treatment option for you. If no immediate appointments are available, you can choose to be contacted when something opens up.  Please note that Intuitive Wellness currently provides services to individual clients ages 18 & over. 
  • Please visit www.wvtherapist.com before completing this request to review information on services offered, specialties, insurance and rate information. 
Email *
Mobile Phone - By providing this you are agreeing to receive text messages from Intuitive Wellness regarding new client openings. (Optional) 
Visit Type
 *
How would you like to be seen? (Please note that due to licensing restrictions for telehealth, you must be located in the state of WV or VA at the time of your appointment.)
What state will you be located in for telehealth sessions if applicable or necessary? *
Availability *
What is your availability for appointments? 
  • Please select all times you are available or choose N/A for days you aren't available at all.  
  • All times below may not be available, but will help filter you into your preferred time slot. 
Any
9am
10am
11am
1pm
2pm
3pm
4pm
N/A
Tuesday
Wednesday
Thursday
Frequency *
If you have a preference for how often you would like to meet, please estimate below.  (This simply helps in determining what openings might work for you.  Most often we will determine this during our first meeting)
Insurance Plan - PRIMARY *
  • Please read below carefully. Intuitive Wellness accepts the following plans:
  1. PEAK Health (WVU Medicine - Processed at Enhanced Tier)
  2. All Highmark - Blue Cross Blue Shield/Anthem/FEP Blue/Out of State BCBS (except Medicaid Plans)
  3. PEIA (Public Employees Insurance Agency/UMR - WV). ** The Health Plan is NOT covered.  Plans that start with an H are considered The Health Plan.  
  • Intuitive Wellness is not able to accept any MEDICAID plans, even if they are Highmark, UMR etc.
  • Other plans not accepted will revert to the private pay options below.  
  • Please choose your primary insurance plan category below.
Insurance Member ID *
Please provide your member ID to assure Intuitive Wellness is in network with your specific plan.  (Or N/A for private pay)
Out of Network Plan
If you have an out of network plan you would like to ask about, please list the plan name and member ID here. 
Rate Information

Insurance - Depending on your insurance plan, you could pay anywhere from $0 - $225.00

You will be responsible for what your insurance plan requires as part of your contract with them (copay, coinsurance, deductible) and for any services/charges not covered by your insurance.

Private Pay Rates
  • Depending on the length and type of service, rates vary between $150-$225.
All Clients (Not billable to insurance)
  • No Show Fee - $150 billed directly to client
  • Late Cancellation (Less than 24 hours) - $150 billed directly to client

Waitlist *
If no immediate openings are available, do you wish to be contacted when something opens up? (If you are waitlisted, you will be contacted via email when an appointment time opens up. Please respond within 24 hours in order for the appointment time to be held for you.)
Referral Source *
How did you find Intuitive Wellness?
Provider Name
If another PROVIDER referred you, please include their NAME and REASON for referral? (if applicable)
Concern *
Please provide a general idea of what you are looking for in therapy at this time. 
First Name *
Last Name *
Date of Birth  *
MM
/
DD
/
YYYY
Please add additional questions or information you would like to share here.
Please be sure to review all information regarding insurance plans accepted, hours of availability, rates for services and specialties at www.wvtherapist.com prior to submitting this form to assure I offer what you are looking for in a therapist. 

Please add these email address to your address book to assure you receive updates on openings: april@wvtherapist.com and yourprovider@simplepractice.com.

*If you have requested the waitlist, have not heard from my office within 3 months, and are still interested in getting in, please submit another request or send the office an email.

*If you would like to be removed from the waitlist, and not be contacted in the future, please email me a quick message at april@wvtherapist.com.
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