Contact

Client's Preferred Name *

Client's Date of Birth *

Parent/Guardian Name (if applicable) *

Contact Methods (Check all that apply) *

Phone Email Text

Preferred Contact Method (reminders, bills, etc) *

Email Text

Client's Email (Parent/Guardian if minor) *

Payment Type *

Insurance Self-Pay

Insurance Company (If self-pay, type N/A) *

Member ID (If self-pay, type N/A) *

Please upload a picture of the front of your insurance card. *

Max file size: 20MB

Please upload a picture of the back of your insurance card *

Max file size: 20MB

Client's Phone Number (Parent/Guardian if minor) *

Client's Address (Parent/Guardian if minor) *

Line 1

Line 2

City

State

Zip Code

Country

If you have secondary insurance, please enter it here. *

Secondary Member ID *

Please upload a picture of the front of your secondary insurance. *

Max file size: 20MB

Please upload a picture of the back of your secondary insurance card *

Max file size: 20MB

Is there anything specific you feel like you need from therapy? (type of provider, type of treatment, accommodations) *

What brings you to counseling? (general issues, symptoms, recommendation from another provider, etc) *

What is your preferred availability (days, times that work best for you)? **It it not guaranteed that you will be offered an appointment with your preferred time slot, but we will do our best to accommodate you** *

Are there any specific providers you would like to see? (Check all that apply) *

Kate Fillion, LPC (Clinton, Telehealth) Molly Haynes, LCSW (Clinton, Telehealth) Alexis LaRowe, LCSW (Bethany, Telehealth) Silvia Werbowsky, LCSW (Groton, Telehealth) Yasmin Fabian, LMSW (Groton, Telehealth)

Preferred Modality of Sessions (Check all that apply) *

In Person - Clinton In Person - Groton In Person - Bethany Telehealth

How did you hear about us? *

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