Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Phone
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(###)
###
####
Email
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Will you be self pay or paying for your sessions with insurance?
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Insurance
Self-Pay
Select all possible times you are available for sessions (check all that apply).
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Do you have a preference on therapist assigned? If so, please select who you prefer to be seen by.
*
Privacy and Security
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I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties beside the person whom it is addressed. I give CAGE Counseling Services permission to contact me via the methods selected below.
Consent
*
I agree that CAGE Counseling Services LLC., may receive the information above electronically and may communicate with me. I understand that this form is not a guarantee of services. I also understand that email transmissions are capable of being intercepted, and privacy of any confidential information that is sent or received cannot be absolutely guaranteed. I agree to the terms, risks, and limits.
Message
Kindly provide your insurance details or any other relevant information that may assist us in reaching out to you effectively.