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Name of person completing form *

Name of client (if different from person completing form) *

Phone number for best contact *

Email address for best contact: *

Preferred method of contact *

Phone
Email

(If email is preferred contact method, by choosing this option, you are consenting to MySpectrum emailing you regarding therapy)

Date of birth of client *

Address of client *

Address Line 1

City

State / Province / Region

Postal Code

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Name of insurance carrier *

Insurance/policy number for client *

Phone number on back of insurance card *

What type of therapy are you looking for? *

Individual for self
Individual for child
Family therapy
Couples counseling

How did you hear about MySpectrum? *

What is your primary concern that brings you to therapy today? *

Please provide us with any other information that would be helpful as we schedule you with a therapist

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