Get Scheduled! Transformative Therapy

New client request form · TXT

Complete this short form and we will match you with a therapist who meets your needs and preferences. We will email you with your scheduled appointment info in 2 or less days!

Client Information

Affirmed name (name you go by)

We need the client's legal name and date of birth to set up their file and bill insurance correctly.

Legal first name*

Legal last name*

Date of birth*
Type it like 4/17/1990 or 04/17/1990.

Email*

Which type of therapy are you requesting?*

Client's age*

Parent or guardian's name*

Parent or guardian's email*

Client's email
Optional. If the client has their own email, we can send them appointment reminders.

Which best describes the custody arrangement?*

Both parents or guardians with legal rights need to complete intake paperwork. Please share the other parent or guardian's information so we can send it to them.

Other parent or guardian's name*

Other parent or guardian's email*

Please tell us about the other person joining you, whether that is a partner, a family member, or someone else. If more than two people will attend, our intake team will collect the rest during intake.

Their name*

Their legal name*
This is so we can set up their client file.

Their email address*

Their relationship to the client*
For example, partner, spouse, parent, sibling, adult child.

Do you have any therapist preferences?

Tell us how much each one matters. "Must have" means we will only offer you
someone who fits. "An ally is fine" usually means we can get you scheduled
sooner, because more of our therapists are available to you.

A therapist of color

Must haveI would prefer it, but an ally is fineNo preference

An LGBTQIA2S+ identified therapist

Must haveI would prefer it, but an ally is fineNo preference

A therapist who is nonmonogamy aware

Must haveI would prefer it, but an ally is fineNo preference

A therapist who is kink aware

Must haveI would prefer it, but an ally is fineNo preference

I am open to seeing a Master's level intern

What type of appointments would you like?*

Every one of our in-person therapists offers virtual sessions too, so
choosing in-person does not stop you meeting online when you need to.

Which of these fit your reasons for reaching out? Select all that apply.

Mood and stress

Anxiety or depressionStress or burnoutGrief or lossA big life change

Relationships and identity

Relationship or family concernsSexual identityRace, culture, or identity

Gender-affirming care

Gender identity or transitionGetting a WPATH letter for gender-affirming care

About the letter

I would like ongoing therapy, and a letter as part of thatI only want the appointments needed for the letterI am not sure yet, I would like to talk it through

Health and experiences

Healing from traumaADHD, autism, or other neurodivergenceLiving with chronic illness, disability, or painStress from activism or organizingSomething else (tell us below)

Which kinds of trauma? Select all that apply.

Childhood traumaTrauma in adulthoodReligious traumaMedical trauma

What else brings you in?

Please briefly tell us what brings you to therapy.*

1. Which days are you available? Select all that apply.*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

2. Enter your available times for your selected days:

The more times you give us, the faster we can match you with a therapist.

Monday Availability

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I have a second time on Monday

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Tuesday Availability

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I have a second time on Tuesday

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Wednesday Availability

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I have a second time on Wednesday

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Thursday Availability

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I have a second time on Thursday

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Friday Availability

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I have a second time on Friday

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Saturday Availability

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I have a second time on Saturday

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Sunday Availability

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I have a second time on Sunday

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Any specific times or notes about your schedule?
Optional. Example: only 1-2pm on Tuesdays, or I work rotating shifts.

Payment Information

How will therapy costs be covered?*

Financial Accessibility Application

You can apply for a reduction in therapy fees when money is a barrier to getting care. We use a sliding scale that looks at more than income alone.

It may help to think about your whole financial picture, not just what you earn.

Think about paying lower on the scale if you:

Have monthly student loan payments
Support children, family members, or other dependents
Are a single parent, or the only income in your household
Carry debt that takes up a large part of your income
Receive any form of public assistance
Have immigration-related expenses
Are an elder or a young person with limited resources
Have been denied work because of incarceration history or disability
Work as a public school teacher
Are a student

Think about paying higher on the scale if you:

Own the home you live in, or own other property
Have investments, retirement accounts, or inherited wealth
Travel regularly for leisure
Have more than one income stream by choice
Have high earning potential because of your education, race, assigned gender, class, or other parts of your identity that line up with dominant groups, even if you do not use that advantage

If you pick a lower fee when you can pay more, it limits what we can offer someone who needs it. If you pick a higher fee than you can afford, it adds stress you do not need.

How many people are in your household?*
Count yourself, and anyone you support financially. The table below updates when you type it in.

2026 sliding fee schedule, for a household of 1.

Gross yearly income	Monthly	Fee per session
		$60
		$80
		$100
		$120
		$140
		$160
		$180
		$200
		$225

Based on the 2026 Federal Poverty Guidelines for the contiguous states and the District of Columbia. The poverty level is $15,960 for one person, plus $5,680 for each extra person in your household. Each row is that level at 150%, 200%, and so on.

If you need a fee lower than $60, tell us below. We may be able to connect you with one of our therapy interns, who offer further reduced rates.

What is your monthly household income?*
Before taxes. A rough figure is fine.

Are you a college or graduate student?*

YesNo

Does an adult other than you usually pay for your medical expenses?*

NoYes

Tell us a bit about your financial circumstances.*
This helps us work out a fair fee with you.

Which fee on the scale are you asking for?
Optional. We will talk it through with you either way.

Agreement and signature*

By typing your name below you are confirming that:

You have chosen to self pay, and you will not be using health insurance.
Transformative Therapy & Consultation Services will not bill your insurance unless your circumstances change, and you tell us in writing that you want to use it.
What you have written above is accurate and true.
You may be asked for proof of income to be considered for the largest reduction.
You will email admin@transformativetherapycs.com or send a client portal message with any questions.
Signing this replaces any version of this form you signed before.

Type your full name as your signature*

Date*

Insurance Information

How many insurance plans do you have?*

Not sure which plan is primary or secondary? That's okay. Please answer as best you can and our intake team will help verify your benefits.

Your insurance plan

Insurance plan name*

Blue Cross Blue Shield and Blue Care Network are run by the same company, but they are two different plans. Not every therapist takes both. Please look at the front of your insurance card and choose the exact name printed there.

Second insurance plan

Second insurance plan name*

Which plan is primary?

Upload your insurance card and photo ID*

This takes about a minute on your phone, and it is the step that gets you scheduled fastest. With your card, we can check your benefits and send your cost estimate the same day. Without it, we have to email you, wait for a reply, and your first appointment waits too.

Before you go

If you can find your card in the next minute, go back and choose the upload option. It saves days of back and forth, and most clients who upload now get their cost estimate the same day.

On your phone, tap a field below and choose Take Photo. A photo of the card in your wallet is fine, as long as the numbers are readable.

Your insurance card

Front of card

Back of card

Is the client the subscriber on this plan?*

The subscriber is the person the plan is under. For a child on a parent's plan, the subscriber is the parent.

Subscriber legal first name

Subscriber legal last name

Subscriber date of birth
Type it like 4/17/1990 or 04/17/1990.

Your second insurance card

Front of second card

Back of second card

Is the client the subscriber on the second plan?*

Second plan subscriber legal first name

Second plan subscriber legal last name

Second plan subscriber date of birth
Type it like 4/17/1990 or 04/17/1990.

Photo ID

A photo of the front of a driver's license or other ID helps us confirm your benefits.

Phone number
Optional. If you leave your number you are giving us permission to follow up via text, call or voicemail.

Anything else you'd like us to know?

Consent to submit this form

Please review and accept the statement below before submitting.

By submitting this form, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Request My Appointment" you agree to hold Transformative Therapy harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. If you prefer to skip this form and call us to get scheduled our number is 517-798-6745.