New Client Request for Services

Please visit our website for more information about our services at www.Soulsticecd.com

Name

Date

Contact Number

Email address

Preferred Contact Method

Phone

(w/consent to voicemail)

(via HIPAA compliant messaging)

Text

(via HIPAA compliant messaging)

Any

Service Requested

Individual Therapy

Family Therapy

Couples Therapy

Not sure

Service request is for

Adult

Child

List age in comments

Self

Someone else

Specify in comments

Payment We welcome self pay as well as use of your eligible insurance benefits. By choosing to use insurance for behavioral health treatment please be aware that you will have to meet clinical criteria for a behavioral health diagnosis and that your provider is required to report that diagnosis to your insurance plan. Insurance will only pay for services deemed medically necessary. We would be happy to further explain this insurance requirement and answer any questions that you may have regarding your payment options prior to beginning services. You can also review more insurance and payment options information under the About Therapy tab in the main menu of our website at www.soulsticecd.com

Self Pay

Insurance

Would like to discuss

Please contact Soulstice via phone or email

Insurance Payer

If self pay comment "n/a"

Appointment Availability

Morning

9am-11am

Afternoons

12pm-3pm

Evenings

3pm-8pm

Flexible

Message

Please briefly describe your concerns. Some examples may include: depression, anxiety, behavioral problems, general stress, relationship problems, communication issues, infidelity, anger management, trauma, parenting concerns, etc...

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New Client Request for Services

Please visit our website for more information about our services at www.Soulsticecd.com

Please visit our website for more information about our services at www.Soulsticecd.com

Soulstice Counseling and Development, LLC