Intuitive Wellness LLC | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Preferred Contact Method

Intuitive Wellness will use this to contact you when an opening becomes available or to answer questions included at the end of this form.

Reason for care

Please provide a general idea of what you are looking for in therapy at this time.

Limited to 600 characters

Administrative

Referral source

How did you find Intuitive Wellness?

Referral from Provider

If another PROVIDER referred you, please include their NAME and brief REASON for referral? (if applicable)

Billing & Payment

Payment method

Would you like to use your insurance benefits or private pay?

Who is your primary insurance carrier?

The below insurance carriers are in network for Intuitive Wellness.

Primary Insurance Member ID

Please provide your member ID (including any letter based prefix) to assure Intuitive Wellness is in network with your specific plan. (Or N/A if choosing private pay)

Private Pay

If you have insurance you’re not planning to use or that isn’t accepted, please list the plan below. Some plans may require an opt-out form. (Enter N/A if you’re using insurance.)

Client Preferences

Preferred appointment times

Choose all that apply. Appointments are scheduled on Tuesday/Wednesday/Thursday from 9am-4pm

Anytime Tuesday 9-12 Tuesday 1-4 Wednesday 9-12 Wednesday 1-4 Thursday 9-12 Thursday 1-4

Preferred location

What state will you be located in if telehealth is preferred or necessary?

Telehealth - Please note that due to licensing restrictions you must be located in the state of WV, VA, or PA at the time of your appointment.

Frequency

Please select how often you would like to attend therapy if you know at this time.

Waitlist

Would you like to be added to the waitlist if no immediate openings are available?

Additional Information

Please include any additional information or questions here.

Limited to 600 characters

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.