Begin the Intake Process - Embrace Therapy LLC

Begin Our Intake Process

Thank you for connecting with us at Embrace Therapy. If you are interested in seeking treatment with us. Please complete the information below so we can begin the intake process. Once we receive your information, you will be contacted to complete a clinical consultation and match you with the therapist that will best meet your needs.

Name*
First Last
Date of Birth*
MM
DD
YYYY
Cell Phone
Phone
Email
Insurance Name
Insurance ID #
Primary Policyholder if different
First Last
Date of Birth of Policyholder, if different
MM
DD
YYYY
Brief description of symptoms, concerns, or thoughts needing therapy?*
Is Telehealth OK? We are not physically in the office yet.
- Yes
- No
Please check the general time of availability for your sessions.
- Day
- Mid-Afternoon
- Evening

Begin Our Intake Process

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