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A Path to Wellness Getting-to-Know-You Questions
Please use this HIPAA secured form to help us get you started on a path to wellness. Your answers will help us get you started with greater ease.
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Email
*
Your email
Today's Date
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MM
/
DD
/
YYYY
PLEASE NOTE: We do not offer psychiatry and medication management. We are happy to make referrals.
What is your legal name?
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Please list your name as it appears on your insurance card, if applicable, or government ID.
Your answer
What is your preferred name?
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Your answer
Preferred pronouns
*
Choose
She/Her
He/Him
They/Them
What is your 10 digit phone number? xxx.xxx.xxxx
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Your answer
Where do you live? (123 Main St., Anywhere, STATE 12345)
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Please provide your address that's associated with your insurance, if applicable.
Your answer
Which best describes your physical location?
*
State regulations require therapists to be licensed in the state where the client is located at the time of the session.
Within North Carolina
Within Pennsylvania
Within Oregon
Within Florida
Other:
Date of Birth
*
MM
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DD
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YYYY
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