Psychotherapy Self-Referrals

Please use this form if you are interested in receiving

individual or couples psychotherapy services.

Date and time

Month

Day

Year

Time

HoursMinutes

First name

Last name

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Preferred contact method:

Phone

Are you interested in individual therapy or couples therapy?

Individual Therapy

Couples Therapy

What is your preference of service location?

In-office only.

Telehealth only.

Possible mix of both in-person & telehealth.

Do you plan to use insurance or be private pay?

Using Insurance

Private Pay

If using insurance, please provide (1) insurance company name, (2) insurance company phone number, (3) subscriber name & birthdate, (4) policy and group number. If private pay, please put "private pay" or "N/A."

Please briefly describe your current situation and what prompted you to inquire about psychotherapy services.

How did you hear about us?

Psychotherapy Self-Referrals

Kimberly Fazzini, LCSW