New Client Intake Form

Interested in becoming a client of Sol Therapy? Fill out some info and we will be in touch shortly! We can't wait to hear from you!

What services are you interested in?

Therapy

Medication Management

Both

Would you prefer your visit be in office or a video / audio conference (Telehealth)?

In Office

Telehealth

Do you prefer email or phone communication?

Phone

Preferred Days / Times For Appointments

Name

First Name

Last Name

Date Of Birth

YYYY

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Social Security Number

*We ask for this in case the insurance company needs this to verify coverage status.

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

Insurance Carrier

Insurance Member ID Number

(including any letters)

Text