New Client Contact Request Form

Resilience Therapy + Assessment Services

3408 Woodland Avenue, Suite 102, West Des Moines, IA 50266

515-267-1996 (phone)
Info@resiliencedsm.com

Client Information

First name

Last name

Date of birth

Current age

What type of insurance will you be using?

Email address

Phone number

Please note that unless expressly asked not to, we will likely initially reach out to you via email, so please provide an email address that you check regularly. In the event that we try to reach you by phone, do we have permission to leave a voicemail?

Yes

Please select the service(s) you are requesting.

Individual therapy for myself

Couples therapy

Individual therapy for a child

Family therapy

Psychological testing for myself

Medication management

Psychological testing for a child

Name of primary care provider

Clinic name for primary care provider

Partner Information

First name

Last name

Date of birth

Phone number

Email address

Parent or Guardian Information

Parent name

Parent phone number

Parent email address

Parent #2 (if applicable)

Parent #2 phone number

Parent #2 email address

Do parents reside in the same household?

Yes No

Do both parents agree with and consent to the child being assessed?

Yes No

If the clinician you requested is not available, would you be open to referral to one of our colleagues?

Yes

If the option were available, would you be willing to meet virtually for some or all of your appointments?

Yes

What is the reason you are seeking care at this time? Please provide any additional information you would like us to have about your request.

What days/times are you available for appointments?

How did you hear about us?

Your information will be encrypted.