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) Dr. Molly Haynes, DSW (Clinton, Telehealth) Alexis LaRowe, LCSW (Bethany, Telehealth) Silvia Werbowsky, LCSW (Groton, Telehealth) Julia Driscoll, LPC-A (Clinton, 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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