Weingarden Psychological Services

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Billing & Payment

Payment method

We require credit card information if using insurance or out-of-pocket - you will be prompted to fill this in once your appointment is accepted.

Insurance details

We require this information is you wish to use insurance.

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Is there anything that the practitioner needs to know?

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

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Therapy preferences (we cannot guarantee to accommodate all of the following, but may help to match you with a therapist):

What worked / didn't work in the past? Active, passive or moderate therapist? Skill focused or depth focused? Male or female therapist?

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.