Birch Counseling, PLLC | 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

State

Select the state you live in

What is your gender?

Please note this information becomes a part of your record with us. This question is optional.

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay? We are In-Network with Aetna, Cigna, and BCBS (except for Blue Home and Blue Local).

Insurance details

If you would like to use insurance, what is your insurance?

Limited to 600 characters

Client Preferences

Preferred appointment times

Select as many as apply.

Morning Afternoon Evening

Preferred clinician

Select a clinician from the list

Is there anything additional that you would like us to know?

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

Limited to 600 characters

If your preferred clinician does not have availability, are you interested in connecting with another one of our providers?

Yes, First Available No I'm not interested in other providers. I'm not sure yet.

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.