Assure Therapy Center | SimplePractice

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Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What kind of care is being sought?

Individual Counseling Couple / Marriage Counseling Pre-Marital Counseling Family Counseling Reunification Counseling Parenting / Coparenting Counseling

What are the main concerns or areas where support is needed?

Briefly describe the areas of concern to help us understand your need. There will be an opportunity to provide more detailed information for your counselor on the intake forms.

Limited to 600 characters

Were you referred to our practice by any of the following sources?

Medical Provider Mental Health Provider Attorney or by a Court Order NONE OF THESE APPLY

Billing & Payment

How do you plan to pay?

Note: We do not accept Medicaid or Medicare. These plans do not allow for out-of-network reimbursement for services.

Out of Pocket (Self Pay) In Network Insurance (BCBS, Cigna, Aetna, UHC/Optum) Out of Network Insurance - Self Pay & Insurance Superbill for possible reimbursement

Client Preferences

Preferred Method

Reunification, parenting/co-parenting counseling, and court ordered counseling, is typically provided in person. However, exceptions may be considered on a case-by-case basis depending on the circumstances.

In-person Telehealth

What days are you available?

We offer in-office and telehealth appointments Monday through Thursday. Friday, Saturday, and Sunday appointments are available with Brooklyn via telehealth only.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred appointment times

Select all that apply.

Morning (10am to 12pm) Afternoon (12pm to 3pm) Late Afternoon (3pm to 5pm) Evening (5pm to 7pm)

Is there anything else you would like us to know? (Optional)

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.