New Client Appointment Request Form

Use the form below to tell me about your treatment needs, and I will contact you to discuss options within my practice or in the community. To help me best serve your inquiry, please provide the following client information and the primary reason(s) for seeking services. As always, thank you for providing me the opportunity to partner with you in your treatment goals.

Today's Date

Demographic Information of Person Completing Form

Preferred Title

Mr. Mrs. Miss Dr.

First Name

Last Name

Birthdate of Person Completing Form

Person completing form is the ____

Client Parent Grandparent Aunt/Uncle Legal Guardian Referring agency

Private Email Address

Primary Phone

(Area Code) XXX-XXXX

Phone type

Home Cell Office

Secondary phone (optional)

(Area Code) XXX-XXXX

Phone type

Home Cell Office

Home Address Line 1 (college students please provide local address)

Street Address

Home Address Line 2

Apt/Suite

Home Address Line 3

City, State, Zip

Child Demographic Information (if applicable)

Child Name

First and Last Name

Child Birthdate

Child Home Address Line 1

Street Address

Child Home Address Line 2

Apt/Suite

Child Home Address Line 3

City, State, Zip

Education Information

Name of client's school/university

Referral Information

Referral Source Please let us know how you learned of our practice.

Personal (e.g. friend, family, colleague) Professional (e.g. doctor, teacher, social worker) Insurance Carrier Psychology Today Social Media Other

Please specify below

Other referral source

Insurance Information

Insurance Carrier

Blue Cross Blue Shield United Healthcare I do not intend to use insurance Other

Please specify below

Other Insurance Carrier

Please note that this practice is not in-network with this carrier

Policy Holder Name

First and Last Name

Policy Holder Date of Birth

Policy Holder Home Address

House Number, Street, City, State, Zip Code

Please upload pictures of the front and back of your insurance card This information is required to verify benefits before speaking to the provider

Add file

Please upload a file

How Can We Help?

Please briefly describe your presenting concerns so that I can make an initial assessment of your treatment needs and determine fit/appropriateness of this practice.

Please note that this is a secure and encrypted form.

When Can We Contact You?

Your information will be encrypted.