Evolutionary Psychotherapy, PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay? We require a credit card on file to secure your appointment. For a complete list of insurances and self-pay fees, please visit this link: https://www.evolutionaryholistichealing.com/faq

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning (8-11am) Afternoon (12-4pm) Evening (5pm-8pm)

Preferred Location

In-person Telehealth Hybrid

Is there anything you would like our intake coordinator to know?

For example: what you'd like to focus on, clinician preference, insurance or payment questions, etc.

Limited to 600 characters

Is there anything you'd like us to keep in mind when connecting you with a therapist?

If you have a therapist in mind, please let us know who you'd like to work with! We do our best to honor all requests. Please keep in mind that not all therapists accept all insurances. We prioritize insurance and date and time preferences when assigning clinicians.

Limited to 600 characters

Before being scheduled, I would like to schedule a call with the intake coordinator

If you would like to schedule with our intake coordinator, let us know, and she will send you a link to schedule some time to meet with her.

Yes, I'd like to schedule a meeting with the intake coordinator prior to being scheduled with a therapist. No, I'm happy to be scheduled with a therapist without meeting with the intake coordinator. I understand I will receive a confirmation email with details confirming my appointment with my therapist, location details, and that there is 48 hour cancellation policy.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.