Request for Services

Please complete this form to request services including, skills training, group therapy, letter writing, assertive communication, self-regulation and other targeted 10 to 20 session interventions. We offering cash pay individual therapy services with our doctoral practicum student. We do not offer any other ongoing individual therapy at this time Once your request has been received, we will send intake documents to help you get started. Please be as thorough as you can when completing this form. The more information we have, the faster and more effective our services can be.

Date completed

Name (first/middle)

Name (last)

Name descriptor Please describe the name you have included.

Legal name Preferred name

Legal name

Full legal name if different from preferred name

Date of birth

Gender

Pronoun(s) Select all that apply

He/his

She/hers

They/them

Other/not listed

Pronoun(s) detail

Describe your pronoun if it isn't listed

Address

Street address including street number, suite, apartment etc.

City

State

Zip code

Email address

Phone number

Voicemail Is it ok to leave a voicemail at this number?

Yes No

Comments about service

Is there anything you would like to say about the service you are looking for?

How would you like to pay for the services?

Cash pay/Out of pocket

Commercial insurance

OHP insurance

More than one insurance plan

What is the name of your insurance Payer?

enter "Cash" if paying out of pocket

How can we help?

Please say a bit about what brought you here today for assistance. What problems are you having, and what are you hoping to accomplish?

Current concern

Previous diagnoses

list any previous mental health diagnoses or assessment services and approximate dates. In order to provide service that insurance will reimburse for, we have to have a diagnosis. If you have never had a diagnosis, but are having problems that are getting in the way for you, state this here. If you are experiencing distress or dysfunction in your life you will likely meet the criteria for a diagnosable condition and this will be assessed during your first, intake appointment

In this section say a bit about any problems you are currently having in the following areas. If you aren't having any problems, or the area does not apply, you may use "N/A" or "no problems" in that section:

At home with daily chores and routines, paying bills, scheduling and attending appointments and keeping track of other responsibilities

At work

At school

In your relationships with family, friends, and/or significant others

With your physical health

With your mood and enjoyment of life

Future hopes and plans

Current Providers

Please list any current treatment providers you have for physical and/or mental health. We will not contact anybody listed without your permission and a signed release, but knowing who you are currently seeing helps either way.

Name of provider

List the name of the professional if applicable

Place of service

Where do you receive care from this person? Please list the name of the clinic, hospital or organization

Name of provider

Place of service

Name of provider

Place of service

Thank you! We will be in touch about your request within one week of your submission. We will make every attempt to respond in the next 1 to 2 days.

Your information will be encrypted.

Request for Services - Treatment