Ala Therapy Collective | SimplePractice

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

Date of birth of the person who will be in therapy.

Administrative

Inquiry reason

How did you find us?

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

If using insurance: carrier name, member ID, and the insured's full name and date of birth if the plan is under someone else (a spouse, parent, or sponsor). Then upload the front and back of your card below. Complete inquiries are reviewed and responded to first. Inquiries with missing information are set aside until we receive the missing details, which can add significant time

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Sponsor SSN or DoD Benefits Number (TRICARE only)

TRICARE verifies coverage through the service member's information, so we need the sponsor's SSN or the DoD Benefits Number from the back of your card. This form is HIPAA secure, and we only use it to verify your benefits.

Do you have secondary insurance?

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Preferred modality

Is there anything that the practitioner needs to know?

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.