Acorn Therapy, PLLC | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

What brings you to therapy at this time?

Limited to 600 characters

Billing & Payment

Payment method

How do you plan to cover services?

Insurance Plan Name

If you have coverage under more than one insurance plan, we will need information about all plans. If we don't have coverage information for all active plans, this can result in denied claims, a pause in services, or additional charges. If you have dual coverage through a non-Medicaid and a Medicaid (Apple Health) plan, please list the non-Medicaid plan as your primary.

Insurance card upload

Upload a photo of your insurance card

Member ID

Relationship to Subscriber

Self Parent Partner or Spouse Other

Primary Subscriber Name and Date of Birth

(If not self)

Secondary Insurance Information:

(If applicable)

Limited to 600 characters

Client Preferences

Preferred clinician

Select a clinician from the list

Is there anything you would us to know or questions we can help to answer?

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

Limited to 600 characters

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.