First Name
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Last Name
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Email
*
Phone
*
How do you prefer to be contacted?
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Phone
Text (SMS)
Email
Date of birth of the client
*
What times work best for you?
Mornings (8am-11am)
Afternoons (12pm-4pm)
Evenings (5pm-8pm)
Which Therapist Would You Like to Work With?
Anyone is great!
Justine Alemany
Ashley Aplin
Alisa Davis
Glo De Jesus
Sarah Doan
Rachel Elzey
Jennie Gintoli
Kendal Hansen
Jaitesha Hanson
Brittany Joseph
Francia Pierre
Sara Sharp
Meredith Chrystie
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What type of appointment are you seeking?
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Medication Management
Therapy
Both
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Would you prefer virtual or in-person sessions?
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In-person
Virtual
First Available
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If in-person, which location do you prefer?
Does Not Apply
Riverview
Temple Terrace
Either Location Is Fine
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If seeking therapy, what kind of therapy are you looking for?
Individual
Family
Couples
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What insurance do you have?
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Aetna
BCBS/Florida Blue
Cigna
ComPsych
Humana
Lyra
Medicare
United Healthcare
Self Pay
Tricare
Other
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What is your member ID number or authorization code if using Compsych? (required if using insurance or EAP)
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Any questions or additional information we should know:
How did you hear about our practice?
Word of mouth
Internet search
Social media
Referral from another provider
Other
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