New Client Inquiry Form

Client Information

Name

Email address

Phone number

City, State, Zip Code

Date and Time

If you prefer to request a specific appointment time, click here to access our online scheduler.

Date

What days work best for you for appointments?

Time

What times work best for you for appointments?

About Your Appointment

What brings you to therapy at this point in your life?

Anything else you'd like to share is welcome.

Insurance Verification

We accept BCBS PPO, Blue Choice PPO and Aetna PPO. If you plan to use insurance, please provide the following information, so we may verify your insurance.

If you have another insurance provider, we also accept out-of-network benefits. By using this option, you may be reimbursed for some of your therapy costs.

Insurance Provider

Date of Birth

Month, Day and Year

Member ID #

Group ID #

Phone number on back of your insurance card

Primary Policyholder Name and Date of Birth (if someone other than yourself)

Do you have a secondary insurance provider? (If so, please indicate the policy and number below).

Comments/Questions

Insurance Card (please upload a copy of your insurance card)

Add file

Please upload a file

Thank you for completing our Client Inquiry form. We will be in touch within 24-48 business hours.

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New Client Inquiry Form

Client Information

Date and Time

About Your Appointment

Insurance Verification

Mindful Healing Counseling