New Client Contact Request Form

Resilience Therapy + Assessment Services ~ A Collaboration of Independent Clinicians

Please correct the errors described below.

Resilience Therapy + Assessment Services

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

515-267-1996 (phone)
515-207-1996 (fax)
info@resiliencedsm.com

First name

Last name

Email address

Phone number

Do we have permission to leave a voicemail?

Yes

Preferred method of contact

Name of primary care provider

Clinic name for primary care provider

Date of birth of the intended client

What type of insurance will you be using?

If you are requesting services for someone else, please explain and provide the name of the intended client.

Please select the service(s) you are requesting.

Individual therapy for myself

Couples therapy

Individual therapy for a child

Family therapy

Neuropsychological or psychological testing for myself

Medication management

Neuropsychological or Psychological testing for a child

Concussion care / Sports neuropsychology

Behavioral sleep medicine

Testing accommodations consultation

Workplace wellness consultation

Medico-legal consultation

If you know the name of the clinician you are requesting, please select here.

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

Yes

What is the reason you are seeking care at this time?

What days/times are you available for appointments?

How did you hear about us?

Your information will be encrypted.

Resilience Therapy + Assessment Services

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

515-267-1996 (phone)
515-207-1996 (fax)
info@resiliencedsm.com

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