Client's Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### May we contact you via text message for scheduling purposes only? Yes No Email * Insurance * Aetna Blue Cross Blue Shield Cigna Tricare Prime Tricare Select United Healthcare Medicaid/Medicare Self Pay (I will not use insurance) Other Message (e.g., individual counseling, couples counseling, preferred time of day for appointment, etc.) Thank you! We will reach out to the client.
