First Name
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Last Name
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Phone
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Email
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Whom are you seeking therapy/counseling for
Self
Couple
Child/Teen
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First Name of Person Receiving Services
Last Name of Person Receiving Services
Date of Birth of the Person Receiving Services
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What insurance or EAP program you will be using for billing?
Aetna
Amerihealth Caritas
Anthem Blue Cross Blue Shield
Blue Cross Blue Shield
Buckeye Health Plan
Caresource
Cigna
Compsych (EAP)
Curalinc (EAP)
GEHA
Health Advocate (EAP)
Medical Mutual
Meritain
Molina
Optum
Oscar
UMR
United Healthcare
United Healthcare Integrated Services
Other or Self Pay
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Other or self pay selected
How would you like to receive services?
In-person Only
Telehealth Only
Open to Both
Briefly describe the issue you would like to work on
Would you like first availability or work with a specific clinician?
First available
Stacey Huntwork
Sonja Josselyn
Kanisha Malone
Chris McKillip
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What’s the best way to contact you?
Text
Email
Phone Call
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How Did You Hear About Us?
Email and SMS Text Message Risk Acknowledgement and Use Consent
I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Tell the World Wellness therapists, providers, and/or office staff communicating with me via email or text message
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