CARE Institute | SimplePractice

CARE Institute Send Message

Your info

First name

Last name

Phone

Client's info

Is the client a minor?

Yes No

First name

Last name

Phone

Reason for care

Please select the reason for seeking care.

Anxiety PTSD Grief Depression Substance Use Acute Trauma Couples Therapy Family Therapy Family Mediation Other

What kind of care is being sought?

Cognitive Behavioral Therapy Eye Movement Desensitization and Reprocessing Therapy Trauma Focused Cognitive Behavioral Therapy Addiction Counseling Couples or Family Therapy Family Mediation 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

Clients date of birth

Clients address

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Please summarize the patients current treatment plan including any relevant prescribed medication(s).

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Billing & Payment

Insurance details

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Insurance card upload

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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.