First Name
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Last Name
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Email
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Phone Number
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What is the best way to reach you?
Call
Text
Email
Address
Address
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City
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State
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Postal code
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Client's date of birth
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Preferred Treatment Focus
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Anxiety or OCD Treatment (age 14+)
Anxiety or OCD Treatment (child)
Parent Coaching & Support
Body-Focused Repetitive Behaviors (BFBRs)
Depression
Tics or Tourette's
PTSD or Trauma
Medicaid Treatment for Anxiety, OCD, or related issue
Psychological Assessment (formal diagnostic testing)
Other
I'm not sure, I'd like a recommendation
Brief message about how we can help:
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We accept private pay for treatment, as well as CO Access Medicaid (Colorado Access- Regions 3 & 5, CHP+, DHCP)
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I understand
How will you be paying for services?
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Private Pay
Medicaid
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For Medicaid enrollees, please list your Health First Colorado ID Number below. Please note- we only accept Colorado Access Medicaid plans (Denver, Adams, Arapahoe, Douglas, and Elbert counties)
Appointment availability
Mornings
Afternoons
Evenings
Flexible
Would you prefer in-person or virtual treatment?
In-person
Virtual
Options for both
No strong preference
How did you hear about us?
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Any other information that would be helpful for us to know?
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