Liv'n With A Purpose | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Please add your FULL address including state and zip code

Administrative

Referral source

Enter how you were referred to our services.

Driver's license upload

Do not upload sensitive financial information such as credit card information.

COURT RELATED: DUI/DWI, DV, Criminal, Traffic, Family, Divorce, Child Custody...etc.

Please choose all that apply. Please also let us know detail why you have an open case, in the "In your own words, what is your reason for seeking therapy?" section. Please note, there are cases we will not write a letter for. We will discuss that during the consultation.

I am on Probation, Parole or Diversion I have pending charges or an open case I will need a letter to prove I am in therapy and progressing Does not apply to me

Billing & Payment

Payment method

How do you plan to pay?

Using insurance or EAP - Please list your Insurance or EAP company name here.

Please note: we do not take all plans from the main insurance company. This will also give us your copay/co-insurance amounts. If you have Colorado Medicaid, and do not have a copy of your card. Please log into the PEAK website to obtain a copy. Lastly, Not all insurance plans include mental health benefits.

Insurance card upload

Upload a photo of your insurance card

If you are not the primary card holder and its under a spouse or parent, please provide the following:

NAME, DATE OF BIRTH, ADDRESS with state/zip, RELATIONSHIP TO YOU, PHONE NUMBER

Limited to 600 characters

Do you give us permission to verify your benefits to ensure you have mental health coverage and verify any co-pay or co-insurance amounts?

YES NO Not till after the consultation

Client Preferences

Preferred appointment times

Each therapist has their own schedule. Please list what time frames work well for you for the consultation call which is 15-20 minutes and over the phone.

Morning 7am-11am Afternoon 12pm-4pm Evening 5pm-7pm

In your own words, what is your reason for seeking therapy?

For example: what you'd like to focus on, what diagnosis have you had in the past? ... ect

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.