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New Client Information

Hello! Please use this form to inquire about our services.
Once you submit this form, a member of our client intake team will contact you within one to two business days with information on the next steps to begin working with us.

If you'd like a faster response, feel free to call or text us at (385) 313-0615.

Client Information

Email*

First name*

Last name*

Phone*

Please check to confirm that you agree to receive text messages or phone calls to the phone number provided. Message and data rates may apply. You can opt out at any time by replying 'STOP.'

Client's city of residence

Would you like to use an insurance plan?*

Insurance Information

If planning to use an insurance plan, please provide your plan information and we will verify the coverage of your benefits.

Who is the client's insurance provider?*

Client's legal first name (on insurance card)

Client's legal last name (on insurance card)

Please input the client's insurance card member ID.

Client's date of birth

Preferences

Use this section to select services and preferences.

Which services are you interested in?

Individual therapy

Couple's therapy

Family therapy

Child Therapy

Group therapy and workshops

Do you have a preferred provider or preferred demographics? If so, please describe below. (optional)

Preferred setting (optional)

Preferred language (optional)

Please answer the following:

Are you currently experiencing an emergency or crisis situation?

Have you ever received care in a hospital for mental health concerns?

Are you currently experiencing suicidal ideations?

Are you currently taking any prescription mental health medication?

Are you concerned about your current level of alcohol or drug use?

Are you currently involved in any legal proceedings?

None of the above apply to me.

Why are you looking for services? (optional)

YOUR MENTAL HEALTH PARTNER

‪(385) 313-0615‬

www.psychologytoday.com

5808 South 900 East

Murray, UT 84121

1450 E 820 N

Orem, UT 84097

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