FULL NAME

PHONE

BIRTHDAY

WHAT ISSUES ARE BRINGING YOU INTO THERAPY?

Have you (or the client if you're completing this on behalf of someone else) been hospitalized for psychiatric reasons within the last 30 days? * *

YES

Have you (or the client if you're completing this on behalf of someone else) had a Suicide Attempt within the last 6 months? *

YES

What time works best to schedule your sessions?

MORNING: 8am-11am

AFTERNOON: 12pm - 4pm

EVENING: 5pm - -8pm

NO PREFERENCE

What type of session are you looking for?

How will you pay for services? *

OUT OF NETWORK Courtesy Billing for BCBS, Anthem , United Health Care, UMR, Optum

PRIVATE PAY

Skip if not using insurance | Please provide the MEMBER ID from your Insurance Carde

Insurance Company

Thank you! We’ll be in touch.

With Precision, we find Clarity to Heal

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Offering virtual therapy by Licensed Clinicians in Texas, Nevada, Pennsylvania, Mississippi, Montana, Florida, Louisiana, New Mexico & Wyoming.

Nationwide availability for Wellness Mentor Programs.

Office hours differ from therapy availability times.

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