Safe Space for Family Healing

Safe Space for Family Healing Send Message

Your info

First name

Last name

Phone

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Administrative

How did you hear about us?

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How would you like to pay for therapy sessions?

Name of insurance carrier

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Reason for care

I am seeking therapy for

Myself My minor child My family (We offer family therapy. We do not offer couples therapy.)

If seeking therapy for a child, what is the child's age?

All sessions take place by teletherapy. Are you interested in video teletherapy?

Yes No

What is the reason for seeking therapy?

Anxiety Attentional concerns/ ADHD Behavioral concerns Depression Grief Stress Trauma Other

Have you had mental health concerns or treatment in the past?

In therapy in the past In therapy now Taken psychiatric medication in the past Taking psychiatric medication now Hospitalized for mental health reasons recently Hospitalized for mental health reasons in the past Attempted suicide in the past Attempted suicide recently Harmed self in the past Harmed self recently None of these apply

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, preferred treatment strategies, etc.

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.