New Client Form

Additional Information

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Contact Us

Connect with Inner Peace Mind✦Body✦Wellness, LLC to start your journey to emotional well-being. Our therapists offer personalized support for challenges like anxiety, depression, school related struggles or maybe you're just seeking personal growth! Take the first step towards a fulfilling life by contacting us.

First Name

Last Name

Date of Birth

Age

Phone Number

Inner Peace Mind✦Body✦Wellness, LLC uses text messaging for scheduling, appointment reminders, and brief communication. Texting is not a secure or appropriate method of communication for emergencies. I understand that message data rates may apply. I understand that I may opt out at any time.

I understand and agree to the above statement with regards to the practice's texting policy and limitations.

Additional Client information/ Preferences:

Person Completing This Form:

Relationship to Client

Parent/Guardian's Name:

Inner Peace Mind✦Body✦Wellness, LLC currently accepts most insurance providers. Please provide us with your insurance carrier information and member ID number. Some individuals/ families may have more than one insurance provider, please include primary and secondary insurance provider information:

Insurance Provider:

Member ID Number:

Additional Insurance Provider Information:

Member ID Number:

Currently Experiencing: Check all that apply

Anxiety

Depression

School Difficulties

Social/ Emotional Regulation

Relationship Struggles

Unbalanced Moods

Type of Session:

Individual Therapy

Couples Therapy

Family Therapy

Preferred Day of the Week:

No Preference

Monday

Tuesday

Wednesday

Thursday

Friday- No availability at this time

Preferred Time of Day

No Preference

Morning

Afternoon

Evening

Preferred Session Method:

No Preference

In Person (Taunton, MA)

Telehealth (virtual)

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