enCircle Counseling | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

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Administrative

Referral source

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Billing & Payment

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Insurance details

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Insurance card upload

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Client Preferences

Availablility for Appointment Times

Please note that flexibility on appointment times may allow sooner placement with clinicians availability.

Morning Afternoon Evening

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.

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Appointment Preference Notes

Please note specific prefences regarding days of the week,time of day, or any other notes that will help your clinician schedule the most appropriate time for you.

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Current Date

Date of Completing Prescreen Form

Is there a preferred clinician you are seeking to work with?

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.