Forward Healing Therapy — Appointment Request Form

您的浏览器中未启用 JavaScript，因此无法打开此文件。请启用 JavaScript，然后重新加载。

EEK! We are so happy you choose to reach out! Please complete this form to schedule with us.

All our therapists have varying wait times. If you are open to working with the first available provider, you will receive an email the following Wednesday from when you complete this form. If you are wanting to work with someone specific, you will still have the option to work with the first available or wait until your preferred provider has an open appointment.

电子邮件地址 *

Your email address *

Name *

Phone number *

City and State your permanent residence is in *

How old are you? *

12 and under

13-18

19 and up

How do you plan on paying for therapy? *

My health insurance

Self-pay

We take the following health insurances, which one do you have?

Please note: We are not paneled with Select Share or SH medicaid/medicare *

Select health - Med, Value, Signature

EMI

PEHP

Blue Cross Blue Shield (Not UofU BCBS)

HMHI (UofU BCBS Employee Plan / not taken by Regina Gulick CMHC)

DMBA (Only taken by Regina Gulick CMHC and Sarah St.Martin, CSW)

VEST EAP

My insurance is not taking at your practice; I am open to using my OON benefits

Tell us: what brings you into therapy? What are you hoping to work on? *

Who are you hoping to work with?

All our therapists have varying wait times. If you are open to working with the first available, you will receive an email the following Wednesday from when you complete this form. If you are wanting to work with someone specific, you will still have the option to work with the first available or you can choose to wait until your preferred provider has an open appointment.

I am open to working with the first available

Jakie Deily, LCSW — waitlisted

Alyssa Hewitson, MSW, LCSW — waitlisted

Regina Gulick, CMHC — waitlisted

Bryn, CSW — open appointments

Sarah St.Martin, CSW, 200 RYT — open appointments

How did you hear about us? *

I accept that I will be receiving email communications from Forward Healing Therapy + After-Therapy™ to stay connected. *

I agree

必填

Thanks for your interest in working with us! We have received your information. We will reach out via email on Wednesdays as therapists have availability.

All our therapists have varying wait times. If you are open to working with the first available you will receive and email the following Wednesday from when you complete this form. If you are wanting to work with someone specific you will still have the option to work with the first available but also let us know if you would like to remain on the waitlist.

向我发送我的回复的副本。

提交

清除表单内容

切勿通过 Google 表单提交密码。

reCAPTCHA

隐私权条款

此表单是在 Forward Healing 内部创建的。举报滥用行为

表单