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New Client Therapy Request Form
IMPORTANT:
ETS is not in-network with any Medicare or Medicaid plans.
ETS does not have any prescribers for medication management services.
ETS clinicians are not able to provide audio-only (e.g., phone) sessions.
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* Indicates required question
First Name
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Your answer
Last Name
*
Your answer
Preferred Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Are you completing this form for yourself? If not, please list your first/last name and your relationship to the potential client. Please note, if the client is legally an adult, he/she/they will need to complete this form themselves.
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Your answer
Email Address
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Your answer
Phone Number (Please indicate Home/Cell/Work)
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Your answer
May we call you?
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Yes
No
May we text you?
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Yes
No
If we may call you, when is the best time for you to be contacted? Please list a few times/days, if possible.
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Your answer
May we email you?
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Yes
No
Will you/client be located in New Jersey during your therapy sessions?
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Yes, my primary residence is in New Jersey.
Maybe, I travel between states often.
No, I do not reside in New Jersey.
Type of Therapy Needed
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Individual
Couples
Family
Availability for Therapy (Please indicate which days/times are best for you)
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Your answer
If you currently have insurance, which company is it through? (Ex. BCBS, Aetna, Cigna, UnitedHealthcare)
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Your answer
How did you hear about Embolden Therapeutic Solutions, LLC?
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Web Search
Psychology Today
Another Provider
Someone I know
Other:
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