Collaborative Marriage and Family Therapy

Collaborative Marriage and Family Therapy Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

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Phone

Name you go by

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State

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Reason for care

What is the reason for seeking therapy?

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What kind of care is being sought?

Individual Therapy Couples Therapy Family Therapy Group Therapy Sex Therapy Other

Administrative

Referral source

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Billing & Payment

Do you have Health Insurance and if so, what plan?

Please let us know your preference for using insurance.

Yes, I have an Aetna health insurance plan Yes, I have a Non-Aetna Health Insurance Plan (not Medicaid/Medicare) I prefer not to use insurance or I do not have insurance I am undecided

Client Preferences

Preferred clinician

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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.

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Availability

What days and times are you available for sessions?

Monday Tuesday Wednesday Thursday Friday Saturday Morning (8am-11am) Afternoon (12pm-4pm) Evenings (5pm-8pm)

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.