New patient scheduling form

Trust Therapeutics, LLC

Please correct the errors described below.

Thank you for your interest in receiving services from Trust Therapeutics. We have a few questions we would like to ask in order to get you scheduled with the most appropriate clinician on staff. Some of the questions may seem intrusive, but the purpose is to match you up with the clinician that can be most helpful to you. If you feel uncomfortable with any questions, please feel free to decline answering.

Telehealth is a form of counseling provided online. It is offered by a licensed or certified therapist via a secure video or phone connection. Although Telehealth is a very convenient way of accessing counseling services, it is sometimes not the most suitable mode of therapy depending on the severity/ complexity of a client's concerns. If our clinical team deems that we cannot provide you with the most appropriate service, we will refer you to another agency.

** Please note you must be 18 or older and have access to your insurance information in order to apply for services. If you are under 18, please also list your guardian's name, phone number, and email address. Guardians must consent to the treatment of a minor.
(for the provision of Telehealth services)
(for the provision of Telehealth services)
(for the provision of Telehealth services)
This is the number on the front of your insurance card
    Please upload a file
      Please upload a file
      Due to high volume, appointments book quickly and we cannot guarantee availability. Please respond within 24 hours of email receipt.

      ** If you answered yes to any of the questions, a clinician will reach out to conduct a further screening to ensure Trust is the best fit for you.

      Please Include phone number and email address if available. Thank you

      For urgent attention dial 911 or text 988 or call 1-800-273-TALK to speak with the Suicide and Crisis Hotline

      Thank you for your time. I will review which clinician would be a good fit for you with a supervisor and one of our staff will be in contact soon.

      Your information will be encrypted.