Initial Intake Request Form

First Name*

Last Name*

Phone Number*

Email*

Preferred Method of Contact (Phone, Text, Email)*

Type of Therapy Requested (Individual, Couples, Family)*

Is this for a minor child? If so, please specify age. *

In Person or Online Preferred?*

Briefly share what you are hoping to address in therapy

How do you plan to pay for therapy? (Insurance, self-pay)*

Health Insurance Provider? (Anthem, Humana, Aetna, Sentara, UHC, Tricare, Cigna, etc.)*

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