Get Scheduled! Transformative Therapy

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

Name you go by

Email*

Which type of therapy are you requesting?*

Client's age*

Parent or guardian's name*

Parent or guardian's email*

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. If more than two people will attend, our intake team will collect the rest during intake.

Their name*

Their email address*

Do you have any therapist preferences? Select all that apply.

I prefer a therapist of colorI prefer an LGBTQIA2S+ identified therapistIf my preferences are not available, I am comfortable with a therapist who is an allyI am open to seeing a Master's level intern

What type of appointments would you like?*

Please briefly tell us what brings you to therapy.*

What is your availability for appointments? For best matching please include all days and time ranges you are available. *

Payment Information

How will therapy costs be covered?*

What happens next

We will email you a short form to complete. Your answers help us set your rate before your first appointment. Please watch your inbox and complete the form as soon as you can so we can get you scheduled.

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?

Would you like to upload your insurance card and photo ID now?*

Sending them now lets us verify your benefits and send your cost estimate the same day. If we have to ask for them later, your first appointment gets pushed back.

On your phone, tap a field below and choose Take Photo.

Client information for the insurance claim

Client's full legal name
The name printed on the insurance card and ID.

Client's date of birth
Type it like 04/17/1990.

Your insurance card

Front of card

Back of card

Subscriber full name
The person the plan is under. If that is you, put your own name.

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

Your second insurance card

Front of second card

Back of second card

Second plan subscriber full name

Second plan subscriber date of birth
Type it like 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.