New Client/Supervision Appointment Request Form

Use this form below to tell us about your consultation, therapy, or supervision needs, and we will contact you to discuss options within Community Impact. To help us best serve your inquiry, please provide the following client/supervision information and the primary reason(s) for seeking services. As always, thank you for providing the opportunity to partner with you in achieving your goals.

Today's Date

Demographic Information of Person Completing Form

Preferred Title

Mr. Mrs. Miss Dr.

First Name

Last Name

Birthdate of Person Completing Form

Person Completing the Form is Seeking

Consultation Supervision Therapy for Self Therapy for Family

Private Email Address

Primary Phone

(Area Code) XXX-XXXX

Phone Type

Home Cell Office

Secondary Phone (Optional)

(Area Code) XXX-XXXX

Phone Type

Home Cell Office

Home Address Line 1

Street Address

Home Address Line 2

Apt/Suite

Home Address Line 3

City, State, Zip

Referral Information

Please let us know how you learned of Community Impact

Personal (friend, family, colleague) Professional (e.g., doctor, teacher, social worker) Insurance Carrier Psychology Today Social Media Other

Other referral source

Insurance Information

Insurance Carrier

Aetna Blue Cross Blue Shield Medicaid Wellcare I do not intend to use insurance Other

Other Insurance Carrier

Please note that this practice is not in-network with this carrier

Please upload pictures of the front and back of your insurance card This information is required to verify benefits before speaking to the provider

Add file

Please upload a file

How Can We Help?

Please briefly describe your presenting concerns or requests so that we can make an initial assessment of your consultation, treatment, or supervision needs and determine fit/appropriateness with Community Impact.

Please note that this is a secure and encrypted form.

When Can We Contact You?

Your information will be encrypted.

New Client/Supervision Appointment Request Form

Referral Information

Insurance Information

How Can We Help?

When Can We Contact You?

Community Impact: Consultation & Psychological Services, LLC