A Place of Growth | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Please enter your address if possible

Street Address

Limited to 600 characters

Reason for care

What is the reason for seeking care?

What brings you to therapy today?

What type of therapy is being requested

Example do you need treatment for anxiety, depression, trauma or ERP or EMDR or if you don't know its okay choose unknown

Is there any current substance abuse?

Are you currently wanting therapy for a current alcohol or drug addiction as we do not treat substance abuse?

Do you have an open Child Welfare Services case with a Social Worker

Any cultural, gender or language requests for therapist assignment

Do you have any cultural or language preferences or gender for your therapist?

Is this court ordered

Billing & Payment

Insurance details just name of company and member ID or just upload in next step if you have them as you aren't required to upload at this time. It is only an option.

Insurance Company

Insurance card upload

Upload a photo of your insurance card

Client Preferences

What days and hours are you available

We are open Monday through Thursday 6a-5:30p and Friday available

In Person or Telehealth or Open to Both

Do you want to come to the office or via video or do you just want the first available

Administrative

Please choose if you want to OPT-IN or OPT-OUT to receive SMS messaging. Messaging frequency may vary. Message and data rates may apply. You can opt out any time by texting STOP. For assistance, text HELP or visit our website at https://aplaceofgrowth.com/privacy-policy for privacy policy and for Terms of Service.

Opt In Opt Out

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.