Collaborative Counseling | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Administrative

Referral source

How did you hear about us?

Billing & Payment

Please share your insurance provider. If your insurance isn't listed please select self pay.

If you have a SECONDARY plan, please choose that as well.

Ambetter BCBS Cigna MS Medicaid, Magnolia, Molina, CHIP, TruCare UHC/Optum Self Pay (Either out of network OR interested in a support group!)

Client Preferences

Is there anything that the practitioner needs to know? Skip if not.

For example: any disabilities, accommodations needed, previous treatment or diagnoses, etc.

Limited to 600 characters

Reason for care

Please briefly describe the main reason you're seeking counseling.

If you are filling this out for participation in a support group, please share the main goal for you/your child participating!

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.