client-intake-form

January 25, 2018 by DNSHSMTH888 Leave a Comment

client-intake-form

Name *

E-mail *

Phone *

Preferred Time and Date *

Why are you seeking therapy? *

Will you be using insurance or self pay? *

Insurance
Self Pay

Who is your insurance provider? (if doing self pay just put "none") *

Are you interested in working with a Resident in Counseling for a Reduced Cost? *

How did you hear about Healing Well Therapy?

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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