Client First Name
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Client Last Name
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Client Date of Birth
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Name of Legal Guardian (complete only if client is a minor)
Email
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Phone
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How do you prefer to be contacted?
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Phone
Text (SMS)
Email
What type of appointment are you seeking?
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Therapy
Medication Management
Both
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If seeking therapy, what kind of therapy are you looking for?
Individual
Family
Couples
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Which Therapist Would You Like to Work With?
Anyone is great!
Justine Alemany
Ashley Aplin
Alisa Davis
Glo De Jesus
Sarah Doan
Jennie Gintoli
Kendal Hansen
Jaitesha Hanson
Francia Pierre
Sara Sharp
Meredith Chrystie
Dr. Chak (Medication Management Ony)
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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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What appointment times would work best for you?
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Mornings (8am-11am)
Afternoons (12pm-4pm)
Evenings (5pm-8pm)
Which insurance do you have? (Please select self-pay if not using insurance)
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Aetna
BCBS/Florida Blue
Cigna
ComPsych
Lyra
Medicare Part B of Florida
United Healthcare
Self Pay
Tricare Select
Tricare Prime
Multiplan/PHCS
ChampVA
Other
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If using insurance, please provide your member ID number:
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If you are using EAP benefits, please provide your authorization code: (We only accept Lyra and Compsych EAP).
Do you have any questions or additional information you would like us to know?
How did you hear about our practice?
Word of mouth
Internet search
Social media
Referral from another provider
Other
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