RTW New Client Registration Form

Full name

My pronouns/term of reference

How would you like us to refer to you?

Phone number

your direct or personal phone number

Email address

Generally for correspondence and video Telehealth links

Preferred communication (Select all that apply) Non-HIPAA-compliant methods cannot be used to discuss Electronic Health Record (EHR) info

Phone calls

Emails

via Hushmail

Text messages

Secure Messages

via Simple Practice, our HIPAA-compliant client portal

Specify safety concerns (i.e., most recent incident, intent, fear for safety, etc.):

Other (specify):

What type of therapy are you looking for? Who will the therapist be working with?

Individual therapy

if you want the therapist to work with one person, although support systems may join at times, check this box

Partner relational therapy

if you want the therapist to work with more than one person in a relationship together, check this box

Family relational therapy

if you want the therapist to work with a family relationship and/or the client is a minor, check this box

Specify

please use the text box below to specify

Specify, if needed:

What days of the week work best for scheduling appointments? (list all days that apply)

What times work best for scheduling appointments? (list all that apply: 8 am-11 am, 12 pm-3 pm, 3 pm-5 pm, 5 pm-7 pm)

What date are you looking to schedule the first session/intake?

How will you be attending appointments? In-person availability is limited and will affect start date. Feel free to contact our admin with more info

In-person only

In-person preferred

Video telehealth only

Video telehealth preferred

Either is fine

I would like the option to use both if possible

How will you be paying for services? *Please consult our FAQs or Insurance pages on our website, or contact our admin for more info.

Self-pay/Out of pocket

Insurance (INN/in-network)

*dependent on benefits, criteria met for covered diagnoses, medical necessity, and focus

Reduced fee (MA-level therapist/intern sessions)

Graduate students/clinical intern therapist, supervised by Amy Rinker, LMFT-S

Insurance (OON/out-of-network)

You will need to contact your provider to verify your benefits--we will let you know what info we need

ARS (adjusted rate scholorship)

Further reduced rate for accessibility and those with financial need ($10 off/intern or $30 off/LMFT/A

Who is your insurance (list all: primary and secondary):

Please write, "N/A" if not applicable to you

Please list your insurance member ID #, primary subscriber name and relationship to you, and your DOB (date of birth).

Email or text a picture of the front and back of your insurance card to admin@rinkertherapyandwellness.com or text 253-350-8763

Are you interested in any of the following therapy modalities? (Select all that apply)

Regular talk therapy

Traditional format of psychotherapy/counseling

Systemic therapy

How do family, education, societal, and cultural systems influence wellness?

Sex therapy

Integration of intimacy, attachment, gender, identity, relationships, and sexuality using the bio-psycho-social-sexual-spiritual model

EFT/Attachment therapy

How do emotions and relationship dynamics play a role?

Art therapy

Integration of somatic and creative expression via optional artmaking

Therapist preference?

Amy Rinker, LMFT-S

Accepting new clients (limited)

Maryssa Beare, LMFT-A

Accepting new clients (limited)

Kennedy Rodarte, BA, MA level therapist/intern

Accepting new clients (limited)

Ashley Peoples, BS, MA level therapist/intern

Accepting new clients

Open to assignment based on therapeutic fit

Unsure

Briefly, is there anything else you want us to know?

Thank you for contacting us! Please provide feedback letting us know how we can improve this Contact Form to increase inclusivity and accessibility.

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