Nurture Family Therapy | SimplePractice

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Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Trauma Other Parenting Support

Please tell us in as much detail as possible why you are seeking care, what kind of therapist would be a good fit, and how we can best support you.

You can be as long or as brief as you'd like, but the more information we have the better we can match you with the right clinician and get you scheduled sooner

Limited to 600 characters

Administrative

Referral source

Enter how you were referred to our services

Preferred Form of Contact

How would you like us to respond to your request?

Phone Call Text Message Email

Billing & Payment

Insurance details

Please tell us what insurance you plan to use

Wellmark or other BCBS plan UnitedHealthcare, United Behavioral Health or other UHC plan Aetna Cigna I would be interested in low cost intern care Medicaid (at this time we are not accepting medicaid clients but we can schedule you with a low cost intern) Other

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred clinician

Select a clinician from the list

No results found.

Is there any additional information that would help us better understand you/your child?

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.