GroundingHearts,Inc. | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Billing & Payment

Payment method

How do you plan to pay?

Client Preferences

Preferred appointment times

What days/time are you most flexible to meet ? (Please note that my availability is subject to change, and all clients have a designated recurring day and time for their sessions)

Morning ( 9:15a-2:00pm) Evening ( 4-7pm) Intensives (scheduled with therapist 3-6/hr sessions)

Preferred session type

Is there anything that the practitioner needs to know? [ Please see www.groundinghearts.com for more info]

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

Limited to 600 characters

Reason for care

In the past 6-months, have you had in-patient hospitalization, Intensive Outpatient Program (IOP), Partial Hospital Program (PHP) or terminated a counseling relationship?

Yes No

Are you currently meeting with a therapist (seeking adjunct therapy)

Yes No

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.