New Client Interest Form

If you are interested in starting therapy, please complete the information below. After receipt of this form, you will be sent an invitation to our Therapy Portal where you will enter your insurance information, payment information, and complete the required intake forms to start therapy. If you have any questions, please email us at admin@horizoncounseling.org

Patient Information

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Parent/Guardian Name (if patient is a minor)

First NameLast Name

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

If you don't answer, may we text you at the number above to schedule your appointment?*

YesNo

How did you hear about us?

We don't share your information with anyone, but like to see how clients hear about us. THANKS!

Do you wish to use insurance?*

Yes (please complete plan information below)No, Cash Pay is preferredFolsom Resident offer (must show proof of residence)

Plan name and Member ID

Please list plan name and member ID

Please add a photo of your insurance card FRONT OF CARD

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BACK OF CARD

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Cash Pay Clients

Student Therapist (sessions may be recorded for training purposes) Starting at $65Associate Therapist Starting at $85Licensed Therapist $180 (only available for virtual appointments)Any option will work for me

Preferred language, besides English?

Could you please let us know your preferred gender for the therapist? We aim to accommodate your preferences to ensure your comfort and satisfaction. If you have any specific requirements or considerations, please feel free to share them.

Name of Therapist you are or want to work with:*

No one, I need a therapistOther

Release to Verify Coverage*

I certify that I (or my dependent) have insurance coverage with the identified agency/agencies, and assign directly to all benefits, if any, directly payable to Horizon Family and Community Services for services rendered. I understand that I am financially responsible for all charges whether or not paid by the insurance. I hereby authorize the clinical staff at Horizon Family and Community Services to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Which office would you prefer? Please Select all that apply:

Telehealth is preferredIn-Person at the West Sacramento - 3960 Industrial Blvd West Sac., #600 CA 95691In-Person at the Folsom - 530 Plaza Drive, Suite 130 Folsom, CA 95630In-Person at the Roseville Office - 1130 Conroy Lane Roseville, CA 95661 or 1700 Eureka Road Roseville, CA 95661

Are you seeking therapy for yourself individually or as a couple?

For myselfAs a coupleBoth

If "As a couple or Both" was selected, please provide partner's name, Birthdate, and email so we can create an account for them as well.

Name, Email, Birthdate

Date*

Date

Items for us to know: Type of therapy you are seeking, days of week, time of day, (not required)

FOLSOM resident special offer: These couples sessions will be conducted by student therapists who are under the direct supervision of a licensed therapist, ensuring high-quality care and support for you and your partner.This limited-time offer is designed to help couples build stronger relationships, improve communication, and work through challenges together, all while supporting the professional development of our student therapists. Folsom resident couples offer only, please upload proof of residency:

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Signature*