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Patient's First Legal Name *

Patient's Last Legal Name *

Patient's Date of Birth *

Who is filling out this form? *PatientParentChildPartnerFriendOther:

Best Contact Number *

Patient's Home Address *

Briefly: what made you/the patient want to begin therapy? *

Are you seeking a particular type of therapy? *Talk TherapyCBT (Cognitive Behavioral Therapy)DBT (Dialectical Behavior Therapy)Trauma TherapyEMDR (Eye Movement Desensitization and Reprocessing)Couples TherapyFamily TherapyChildren’s TherapyAnger ManagementAddiction CounselingGrief CounselingUnsure

Are you seeking a particular type of therapist (i.e., any personal or professional characteristics)? *

Please upload a photo of the front of your insurance card for insurance verification. *

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Please upload a photo of the back of your insurance card for insurance verification. *

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If the picture of your insurance card is not uploading please share the following information: *Insurance companyInsurance IDGroup number

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