First Name
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Last Name
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Date of birth
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Phone
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Email
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Address
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Postal code
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Whom are you seeking counseling for
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Self
Child / Teen
Couple
Family
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Child’s Name (if applicable)
Child’s Age (if applicable)
Relationship to Child (if applicable)
Briefly describe the issue(s) you would like to work on.
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How would you like to receive services?
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In-person Only
Telehealth Only
Open to Both
Would you like first availability or to work with a specific clinician?
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First Available - No Preference
Alexandra Prado, LSW
Caroline Jung, LPCC
Kristin, Lim, LPCC
Our Partners
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Our Partners
Faith Voss, LCSW
Holly Boulanger, LPC
Nancy Vargas, LCSW
Stephanie Wolfe, LPC
Dr. Christy Trombley PT, DPT
Jenny Jacobsen, LPC
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What’s the best way to contact you?
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Text
Email
Phone Call
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Name of Insurance
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No Insurance / Private Pay
Medicaid
United / Optum
Cigna
Aetna
Other
If you selected Other above, please list Insurance Provider:
Insurance Policy Number
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How did you find out about The Therapy Collective?
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Email Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to The Therapy Collective therapists and/or office staff communicating with me via email or text message
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