Power of Choice, PLLC | SimplePractice

Power of Choice, PLLC Send Message

Who would be receiving care?

Me

My partner and me

Someone else

Your info

First name

Last name

Email

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 kind of care is being sought?

Individual Therapy Family therapy Couples/Marital Counseling EAP ESA Evaluations FMLA/Disability Evaluation

Billing & Payment

Payment method

How do you plan to pay?

List the name of your insurance provider below.

If you have more than one insurance please indicate this.

Limited to 600 characters

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.