Pathways by Engage | SimplePractice

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First name

Last name

Phone

Name you go by

Date of birth

Gender

State

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Address

Is there anything else you would like us to know?

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

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Reason for care

What is the reason for seeking care?

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

Billing & Payment

Payment method

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Insurance details

- If you plan to use your insurance, please provide your group and policy number/member ID. Also, be sure to upload a picture of the front and back of your insurance card in the next section.

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred clinician

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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.

Who would be receiving care?

Your info