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

Please make sure you've reviewed our rates and insurance page at https://acorn-therapy.com/rates-insurance

Commercial health insurance (employer-sponsored or individual/marketplace) Self-pay

Primary Insurance Plan

If you have more than one active insurance plan, please provide information for all plans below. Missing coverage information can result in denied claims or additional charges. If you have both a commercial plan and Medicaid (Apple Health), list the commercial plan as primary.

Member ID

If you plan to use insurance, your Member ID is required so we can verify your coverage and network status before scheduling a complimentary consultation or intake appointment.

Secondary Insurance Information:

If you have another active insurance plan, please include the plan name and Member ID here. Otherwise, leave blank.

Limited to 600 characters

Client Preferences

Preferred clinician

If a clinician isn't listed below then they're currently unavailable for new clients. Waitlist requests can be sent to intake@acorn-therapy.com

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.

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.