Approach Therapy | SimplePractice

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First name

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State

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Reason for care

What is the reason you are seeking care?

What issues would you like help with?

Anxiety Behavioral issues Depression Grief Relationship issues Work-Related Stress Parenting-Related Issues Sexual Identity, Self-Acceptance or LGBTQ+ Issues Trauma Help Adjusting to a Recent Life Change Not Sure Yet None of the Above Other

What kind of care is being sought?

Individual Therapy/ Counseling Services Couples Counseling or Family Therapy Medication Management Inpatient Mental Health Emergency Mental Health Other

What mental health concerns or treatment occurred in the past?

Check all that apply

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of the above apply

Administrative

Inquiry reason

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Referral source

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Billing & Payment

Payment method

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Are you looking for a therapist who accepts a specific type of health insurance or reimbursement program?

Yes, AND I am ONLY looking for a therapist who is IN-NETWORK with my insurance or health reimbursement program. Yes, BUT I am OPEN to other options. No, I am open to all options.

Client Preferences

Preferred clinician

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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.