Grace in Chaos Counseling | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

If you're a minor, please provide the name and contact information for your parent/guardian. If not a minor, please write "n/a."

Limited to 600 characters

Email Address

Phone Number

Reason for care

Tell me a bit about what you're looking to explore in therapy, including anything specific you're wanting to address and/or goals you have for therapy.

Share as much or as little as you believe would be helpful for me to know prior to an intake session.

Limited to 600 characters

Have you previously worked with a therapist? If so, please share about your experience, particularly anything you cared for or didn't care for in your work together, as well as any previous mental health diagnoses you may have received.

Limited to 600 characters

Billing & Payment

Payment method

What payment option feels like the best fit for you right now?

Insurance details

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

When would you prefer to have sessions?

9AM-11AM 12PM-2PM 3PM-5PM

Are you interested in telehealth, in-person, or hybrid sessions?

In-person Tele-health Hybrid No preference

What the best way to reach you?

Phone Call Email

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.

Who would be receiving care?

Your info