The Well: Family Support | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

For minors, list the guardian’s name, email, and phone number below. Please do not list guardian contact details as the minor’s above.

Administrative

Inquiry reason

How did you find us?

Client Preferences

How can we help?

Clients/guardians: Briefly describe concerns or questions. Referring professionals: Include referral information, client DOB, phone, and email. For minors, include guardian contact information.

Limited to 600 characters

Reason for care

How can we help?

Clients/guardians: Briefly describe concerns or questions. Referring professionals: Include referral information.

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.