Healing with Play, Inc | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

If you are a parent/guardian filling out this form for a child under 18 yo, please make sure you check the correct box above: Filling out form for ME or SOMEONE ELSE. A client's name and date of birth MUST be added to create a chart in their name.

I understand the above statement

An EMAIL for a minor is not required, please put email and contact phone numbers in the parent/guardian information ONLY (indicated by red asterisk)

I understand the above statement

Please provide home address

Limited to 600 characters

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

How do you plan to pay?

If you plan on using insurance, please indicate Subscriber Name and their date of birth.

We can check your insurance benefits prior to scheduling so we have that information for you at the time of scheduling your appointment. An insurance card must be uploaded to check insurance.

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

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.