We Thrive Together | 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

State

Select the state you live in

Phone number

Administrative

Request Administration to Reach out Through Spruce HIPAA Secure Text?

Be sure you are leaving a phone number that has text messaging.

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

If planning to use OON benefits - be sure to check with your insurance about deductible status and Out Of Network reimbursement rate prior to scheduling. Check on our website fees & investment page to learn more about using Thrizer for OON benefits. List any questions you may have here.

Limited to 600 characters

Medicare Recipients: Our clinicians are opted out of Medicare. This means that you can not receive reimbursement through Medicare for our therapy services.

I understand this and will sign the opt out form provided at intake.

Client Preferences

Preferred appointment times

If you have specific days that are better for you please add that to the "Is there anything the practitioner needs to know" section.

Morning Afternoon Evening Weekend

Preferred modality

Is there anything that the practitioner needs to know?

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

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.