GIA Institute of Psychotherapy

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Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of birth

Administrative

What do you need help with today? (Check all that apply)

Scheduling an appointment Finding the ‘right’ therapist for me I have questions about insurance I want to know your rates I am interested in school advocacy services Internship, Employment or Training Opportunities at GIA Institute Something else

How did you hear about us?

Billing & Payment

We offer a range of clinicians with different fee structures. Some are in network with insurance companies, while others are out of network. If you prefer to work with an out-of-network clinician, you may still be able to use your out-of-network benefits for reimbursement.

If you plan to use insurance, what is the name of your health insurance provider?

Insurance card upload

Upload a photo of your insurance card

Do you receive your insurance through an employer?

If so, please list your employer’s name.

Client Preferences

Preferred method of communication

Whats the easiest way to reach you?

Text Message (SMS) Phone Call Email

I give GIA permission to contact me via (check all that apply)

Text Message (SMS) Phone Call Email

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.