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Alexandria Art Therapy - Prospective Client Information
Thank you for your interest in Alexandria Art Therapy. Please fill out this form to let us know more about your logistical and therapeutic needs.
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Name
*
Your answer
Pronouns
Your answer
Child's Name & Age (if child is prospective client)
Your answer
If you feel comfortable, please provide a brief description of your needs and what leads you to seeking therapy at this time. This may include symptoms, and / or goals for therapy.
Your answer
How did you hear about Alexandria Art Therapy? If a provider referred you, please include their name.
Your answer
Do you plan to use insurance benefits?
BlueCross BlueShield
Out of Network
I have BlueCross BlueShield, but am open to an out-of-network clinician if they have availability sooner
I would prefer to attend sessions:
In person at the Alexandria Art Therapy Office in Old Town Alexandria, VA
Virtually
Open to either mode
For virtual services, in what state are you located?
Virginia
Maryland
DC
Other:
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Availability (please select all that apply):
Mornings (8AM-12PM session time)
Afternoons (1PM-4PM session time)
Evenings (5PM-7PM session time)
Other comments, questions, or things you would like us to know:
Your answer
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