Prospective Client Inquiry form

Please correct the errors described below.

Dear Reader,

Thank you for your interest in my practice. To take the next step, complete the form below and I will get back to you as soon as I can.

Best,

Jane Sproul, MS, LPC

First Name

Last Name

Date of Birth

Email address

Phone number

What is your insurance coverage? I am contracted with the following companies.

Aetna

Blue Cross Blue Shield

Cigna

HealthShare/CareOregon

Moda

Oregon Health Plan

Pacific Source

Providence

Trustmark

Other:

Days of the week you are available for appointments I see clients Monday through Friday

Any week day

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

It varies

Times you are available I see clients between 9 and 4:15 pm most days. I am closed evenings and weekends.

9 am - 12 pm

1 pm - 4:15 pm

It varies

Interest

What is your interest in counseling services?

Please upload a copy of valid photo identification as required by regulations.

Add file

Please upload a file

Please update insurance card if you have obtained new insurance.

Add file

Please upload a file

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide