Willow Wellness Center New Client Inquiry

If this is an emergency, call:

To provide faster service, please complete this form and one of our clinicians will follow up with you with 48 hours.

If you are in crisis or an emergency, do not complete this form.

Your Information

First Name

Last Name

Email Address

Phone Number

Preferred Communication Method

Phone Email

Who can we thank for referring you to us?

How do you prefer to meet for therapy?

In-Person Telehealth

Briefly describe what brings you to therapy now.

Will you be using insurance or self-pay?

Insurance Self-Pay

By providing your insurance information, our office will verify your benefits and coverage as a courtesy.

Subscriber/Member ID

Date of Birth

Do you have a Medicare Supplement or Advantage Plan?

Yes No

Insurance Company

Subscriber/Member ID

Your information will be encrypted.