Centered Practice | SimplePractice

Centered Practice Send Message

Who would be receiving care?

Me

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Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

State

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Reason for care

What is the reason for seeking care?

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Anxiety Attentional difficulties Depression Grief Relationship issues Trauma Other

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Please list both primary and secondary insurances if you have two policies. Is the insurance through an employer or will you be using insurance through a government program?

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Insurance card upload

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Client Preferences

Preferred appointment times

Morning Afternoon Evening

Preferred modality

What would be helpful for the therapist or administrator to know?

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

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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.