Contact Info

First Name *

Last Name *

Email *

Phone *

Partner Name and Email Address *if requesting couples therapy

Therapy Info

How would you like to meet with your therapist? *

In-Person Only

Telehealth Only

Open to Both

How can we help you? *

What days and times are you available for a 10-15 min phone consultation? *

If requesting couples therapy - Partner's Availability for Intake Call

How Did You Hear About Us?

Insurance

What is your insurance carrier and what is your insurance ID number? *

Date of birth

FRONT of Insurance Card

BACK of Insurance Card

Communication Consent

Email Risk Acknowledgement and Use Consent *

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 Downtown Psychological Services PC therapists and/or office staff communicating with me via email or text message

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I agree to terms & conditions provided by the Downtown Psychological Services PC. By providing my phone number, I agree to receive text messages from the business.