Currently we do not accept Medicare
Please provide the First & Last Name, Birthdate, and Gender Pronouns (if you wish to share), and Medicaid numbers if applicable for additional Clients who will attend sessions.
After you fill out this form a therapist will call you for a quick 15 minute consult before setting up an intake with you.
Everything you discuss on this form, or in the future with a Whole Connection therapist, will be kept confidential and stored only in our locked locations. Your privacy is important to us, but we are also trying to make sure that our services are a good fit for you.
If you are completing this form for a couple or family please use the initial “client” fields for the main point of contact and use the couple/family additional information field at the end of the form to add personal information for everyone else who will be joining the sessions. In addition for couple/family, please complete fields with information for all attending members to the best of your ability starting with the question: “Is there any violence in your home currently or in past relationships?”.
Please be aware when filling out the form, that we are mandatory reporters for child and elder (70+) abuse and neglect as well for active suicidal or homicidal plans.
We have a two session intake process. Therapy itself will feel a bit different than the first contact which is a history gathering appointment. Please know that you may not work with the therapist who completes your intake. After completing the two sessions we will determine if we are the right fit for you and we will offer you other referrals if we are not.