Therapy Self-Referrals | KimberlyFazziniLCSW

Todays date and time

Month

Day

Year

Time

HoursMinutes

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Preferred contact method:

Email

Phone

I am interested in...

Individual Therapy

Couples Therapy

Group Therapy

I prefer services...

In-person only

Telehealth only

Possible mix of both

I plan to pay for services...

Using Insurance

Private Pay

If using insurance, please provide the following: (1) insurance company name, (2) insurance company phone number, (3) subscriber name & birthdate, (4) policy and group number.

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

What is your preferred availability for scheduling?:

How did you hear about us?

I understand that by completing this form I am authorizing Kimberly Fazzini, LCSW to review and verify my insurance benefits related to psychotherapy services

Psychotherapy Self-Referrals

Kimberly Fazzini,
MSW, LCSW, CCS

Psychotherapy Self-Referrals

Kimberly Fazzini, MSW, LCSW, CCS

Kimberly Fazzini,
MSW, LCSW, CCS