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Who would be receiving care?

Your info

For insurance verification
Select the state you live in
if not applicable, indicate with N/A
Reason for care
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Limited to 600 characters
If unknown or none, indicate with N/A
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Administrative
For example, referring provider's name, friend, teacher, etc.
Do not upload sensitive financial information such as credit card information.
If unknown, indicate N/A
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Billing & Payment
How do you plan to pay?
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Upload a photo of your insurance card
First, Last
Client Preferences
Select a clinician from the list
For example: what you'd like to focus on, insurance or payment questions, etc.
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N/A if unsure

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.