Name
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First Name
Last Name
Email
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Phone
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How would you like us to contact you?
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Please provide the name, phone number and email address of the other consenting caregiver. If you have sole custody, please type N/A.
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How did you hear about Ensemble Therapy?
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Why are you seeking therapy for your family?
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Check all that apply.
What is the client's age?
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What are the client's pronouns?
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I understand that if I am concerned about my child inflicting harm to themself or others, then I will reach out to one of the crises resources on our FAQ page.
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Ensemble Therapy has a waitlist for services and does not provide crisis services.
Please check the caregiver's current marital status.
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If the child’s caregivers are divorced then a copy of the complete divorce decree MUST be provided to Ensemble Therapy before the family will receive services.
Additional information you'd like us to know
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Are you interested in in-office sessions or teletherapy?
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Specific clinicians may/may not have availability based on your office preference.
Are there any accommodations your family might need for either in-person or virtual sessions?
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Which type(s) of appointments are you interested in?
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Appointment Availability
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We do our best to accommodate our clients' complex scheduling needs. Please note that Fridays, Saturdays, and after school times are the most requested times, hence we are busiest. If you have more flexibility in your schedule, the sooner we'll be able to get you onto the schedule.
Please list all possible OPEN availability below.
Which professional are you most interested in working with your family? (All therapists do have a waitlist so we will reach out to you with estimated availability)
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Check all that apply.
I understand that if there is a legal custody arrangement in place that requires consent from both caregivers for psychological and mental health services, we cannot add you to our waitlist unless both parties are in agreement.
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Would you like to be added to our monthly newsletter?
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All therapists at Ensemble Therapy are private pay, which means we are not in-network with insurance providers. You may wish to consult with your insurance company to inquire about reimbursement for therapy services. We will provide you with monthly receipts, if you request. Reimbursement is considered a matter between you and your insurance carrier. If you would like our handout about seeking information from insurance companies about reimbursement, please check yes below.
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When you push submit on this form, you'll be taken to our calendar to schedule your 15 minute consultation call. Please wait 5-10 seconds to be redirected.
