Client Portal & Referral Form

Name (legal & preferred)

Date of birth

What phone number can we reach you at?

What email can we to reach you at?

Emails & phone numbers for parents/guardians if applicable

Day(s) of the week and time preferences?

Insurance member ID if applicable

Would you prefer in person or virtual therapy? Would you prefer in person or virtual therapy? In person Virtual Hybrid

What insurance carrier do you have? What insurance carrier do you have? Medicaid Cigna Aetna United Healthcare UMR Kaiser Anthem/BCBS Medicare Other Self-Pay or No Insurance

What are you seeking therapy for?

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit" you agree to hold The Compassion Collaborative harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.