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New Client Request
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Name (First and Last)
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Your answer
Email
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Your answer
Phone number
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Your answer
Insurance Type
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Choose
BCBS - (In network)
United Health - (In network)
Medicaid - (In network)
UMR - (In network)
Mountain Health Co-Op
Crime Victim's Compensation
Worker's Compensation
Self-Pay
Cigna
Aetna
Medicare
Other
Reason for Appointment
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Individual Therapy
Couples Therapy
Family Therapy
Psychological Testing
Psychiatric Services
Preferences For Therapy Appointments (Select all that apply)
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I would like to be seen in the Rock Springs Office
I would like to be seen in the Green River Office
I would like to be seen via Telehealth (Video Call)
I would prefer a female clinician
I would prefer a male clinician
Mornings would work best for my schedule
Afternoons would work best for my schedule
Evenings would work best for my schedule
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Psychological Testing (Only if Requesting Testing)
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Pre-surgical (e.g. bariatric surgeries, spinal cord stimulator trials, etc.)
Attention-Deficit/Hyperactivity Disorder (ADHD)
Intelligence Assessment (IQ)
Memory
Pre-employment
Personality/Diagnostic
Autism Screening (does not include the ADOS-2)
Please describe briefly in general terms what brings you to us: (e.g. anxiety, depression, couple's therapy, etc.)
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How did you find us?
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Additional Information (Optional)
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