New Client Appointments

If you are a new client and you would like to request an appointment with one of our providers, please fill out the confidential HIPAA secure form below. By providing us with the information requested, we can more easily and quickly check your benefits and coverage, and pair you with a clinician who best meets your needs and scheduling preferences. Once you have completed the form, our Intake Coordinator will contact you within 1-3 business days to set up an appointment or get added to our waiting list. If you are an existing client, please schedule directly through our client portal.

New Clients Only: Fill in the information below to request an appointment for yourself or someone else.

First Name*

Last Name*

Street Address*

Street Address 2

City*

State*

Zip Code*

Phone*

In order to expedite communication and scheduling, may we text you at this number?

Yes

Email*

Type Your Email Again*

Preferred method of contact?*

If you are requesting the appointment for someone else, what is your full name?

If you are requesting the appointment for someone else, what is your relationship to the client?

If you are looking for couples counseling, please enter your significant other's name, date of birth, and email address.

Preferred Gender Pronouns

Sex (for insurance identification purposes)

Is the client under the age of 18?*

If the client is a minor, are there any current custody or divorce issues?

If you are a divorced or separated parent scheduling for a minor, do you have 100% custody of the minor client, or do share custody with another individual?

If there is a second guardian with joint custody rights, please enter the name and contact details of the other guardian

What services are you inquiring about?*

Due to high demand, some of our therapists may not be accepting new clients. We suggest choosing several possible therapists you are interested in so we can check their availability for you. If you have a first choice, please choose them below.*

Who is your second choice for a therapist?

What days/times are you generally available for therapy? Please be as specific as possible with dates/times (e.g., Mondays between 3pm and 8pm).*

Before we can can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. All information entered is transmitted through a HIPAA compliant form and will be kept confidential.

Legal Name (as it appears on your insurance card)

Date of Birth*

Name of Primary Insurance Company*

If your insurance is not listed above, enter it below:

Group Number*

Policy Number*

Name of Secondary Insurance Company (if applicable)

Group Number for Secondary Insurance (if applicable)

Policy Number for Secondary Insurance (if applicable)

Are you or a member of your family a current or past Cardinal Psychotherapy client?

Yes

Please provide a brief summary describing your goals in therapy or the type of support you are seeking.*

Do you prefer in person or virtual sessions?*

Any additional information to help find a good match for a practitioner please write below:

Please verify your request*