Your Way Therapy | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Do you currently reside in: Virginia, West Virginia, North Carolina, South Carolina, Illinois, Florida, or Texas?

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Administrative

Referral source

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Reason for care

What is your reason for seeking care?

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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.