SDH Wellness | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Name you'd like us to use

If we are utilizing insurance, we will need to have the name associated with your insurance plan as well, if it differs

Pronouns, if you'd like to share

How would you describe your gender?

If we will utilize insurance, we will need to know the gender associated with your insurance plan

Do you have any disability, chronic health conditions, or access needs you'd like us to be aware of?

It is completely up to you if and what you share here

Reason for care

What brings you to your search for a therapist at this time?

Please feel able to share what you are comfortable with, to help our awareness of what you are seeking.

What mental health concerns or treatment have occurred in the past?

Limited to 600 characters

Administrative

How did you find us?

This is helpful for us to know!

Psychology Today Our website found over google or another search engine Insurance Referral EAP Personal Referral Another referral search engine, such as Therapist.com, Thriving Campus, Therapy Den

Client Preferences

Preferred days/ times?

Limited to 600 characters

Preferred clinician

Select a clinician from the list

Is there anything you'd like to share with, or ask, the clinician prior to meeting?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Billing & Payment

If you hope to utilize insurance, please share your insurance plan name so we can support navigating any questions that may connect to insurance

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.