New Client Inquiry Form
Today's Date
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
Parent/Contact Name if different than client
First Name
Last Name
Client Age:
Relationship to Client
Client Date of Birth:
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Insurance:
Blue Cross Blue Shield PPO
Out of Network
Lyra
Not using insurance
Email
example@example.com
Best Day and Time to Call:
Referral Concerns/Symptoms:
Anxiety
Depression
School Issues
Attention Difficulties
Behavior challenges at home
Parenting skills and support
Social Skills
Family Stress
Grief/Loss
Services:
Individual Therapy
Group Therapy
Family/Parenting Support
SSP (Safe and Sound Protocol)
Type of Group
Social CBT
Social Theatre
Daring Way Group
Parenting Group
Other
After School/Evenings Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Other availability:
Mornings
Afternoons
Saturdays
Open to Online Therapy Sessions?
Yes
No
Maybe
Please share how you found us:
Website
Internet Search
Physician Referral
School Referral
Friend
Other Provider
Psychology Today
Other
Name of person who referred you to us:
Name of who referred you
Other information to Share:
Completed by:
First Name
Last Name
Submit
Should be Empty: