TreeHouse Health | 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 is the reason for seeking care?

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

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Please share a brief summary of the concerns you would like to address in therapy

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Administrative

Inquiry reason

Referral source

How did you hear about us?

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Insurance card upload

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Client Preferences

Preferred appointment times

Morning (8:00 am to noon) Afternoon (noon to 3:30 pm) After School (3:30 pm to 8:00 pm) Evening (5:00 pm - 8:00 pm

Preferred clinician

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Please list specific appointment time(s) needed, if applicable

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Where do you want to receive services

In the Office Telehealth In-Person and Telehealth No Preference

Is there anything else the practitioner needs to know?

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.