Intake Request Webform - Powered by Keap

NEW CLIENT FORM

Please complete this form and we will call you as soon as possible to schedule. We look forward to talking with you!

Preferred First Name *

Preferred Last Name *

Phone Number *

Email *

Are You Currently Active Duty Military? *

YesNo

Is the Potential Client at least 18 years of age? *

YesNo

Please note that we only see clients who are at least 18 years of age. If the client is a minor we are happy to send you a referral list of practices who serve minors once you submit this form.

What services are you interested in? *

To select multiple hold down ctrl or command when making your selections

Select your preferred payment/insurance *

Please specify if your chosen payment was "other"

If you want to use insurance to pay for services, we have providers who are in network with Aetna, Cigna, Kaiser, Lyra, Tricare and VA/TriWest. If you have a different insurance you can inquire if your insurance offers "out of network benefits" and if so, we can provide you a "Superbill" to submit to them directly.

**OPTIONAL INFORMATION BELOW**

Type of Therapy Preferred

In personTelehealth (video counseling)Open to either

To select multiple hold down ctrl or command when making your selections

What are you seeking therapy for?

Preferred Pronouns

How did you hear about us?

Doctor/ProfessionalFacebookFriend/FamilyGoogle SearchInstagramMonarchMy Insurance CompanyPsychology TodayOther

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. You also agree to have someone from our team contact you by phone and/or email. *