New Client FormYour journey matters, and we're honored to walk it with you. To help us understand your needs better, we invite you to fill out our new client form. Each detail you share will help us support you better. First Name Last Name Is the client a minor (under 18 years old)? * Yes, new client is under 18 No, new client is over 18 Client Email Address * Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Presenting Concern(s) * Best Availability * Monday Tuesday Wednesday Thursday Friday Saturday Mornings Afternoons Evenings Exclusively Telehealth * I understand all sessions will be held online Insurance * Atena CareFirst BlueCross BlueShield Anthem EAP - Bank of America Kaiser Permanente of the Mid Atlantic Quest Behavioral Health Carelon Behavioral Health Independence Blue Cross Pennsylvania Member ID Number * Birthdate * MM DD YYYY Referred by Message Your intake form has been successfully submitted. Thank you for taking the time to share this important information. We are reviewing your responses and will follow up soon to ensure your onboarding experience is smooth and supportive.
