Therapy Self-Referrals | KimberlyFazziniLCSW

Todays date and time

Month

Day

Year

Time

HoursMinutes

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Email

Preferred contact method:

Email

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.

What is your preferred availability for scheduling sessions?

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