We’re Glad You’re Here

Your First and Last Name *

First Name

Last Name

Client’s First and Last Name *

First Name

Last Name

Phone *

(###)

###

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Client’s Date of Birth *

MM

DD

YYYY

Please indicate what your availability is for meeting with a counselor. Appointments after 4PM are less frequent, so we'd like to especially know if you have availability during the daytime.

Daytime

Evenings

Is it OK if we reach out by text if you cannot be reached by email?

Yes

No

Are you willing to pay out-of-pocket ($75 to $120) for sooner availability in the case of insurance providers' waiting lists?

Yes

No

Are you willing to see an intern for $0 to $45?

Yes

No

Are you willing to meet via telehealth?

Yes

No

I acknowledge that submitting this message does not constitute the beginning of a counselor/client relationship. *

Yes

Acknowledgment of Insurance Responsibility *

If you have more than one insurance plan you must give us information about BOTH plans. This includes if you have Medicaid, a plan through your spouse or parents, an old Cobra plan, etc. If we don't get information about both plans it is highly likely that we will not be paid correctly and then you will end up with the bill and will have to pause services until it is paid. If we have all of your insurance information, this can be avoided.

I understand that it is my responsibility to provide CLA with all information about all insurance plans that I am covered by. Failure to do so may result in insurance not covering the cost for therapy services and that I will be responsible for paying the costs