New Client Registration Form – Family – Wholehearted Healing Collective

Family Therapy

The first step to getting started as a new client at Wholehearted is to complete a New Client form. Once the form is completed, our admin team will review all of your information, including your reason for seeking services, your preferences around which therapist you’d be matched with, and your availability, and then we will be in touch about scheduling a first appointment. After the first appointment is scheduled, your account in the client portal will be set up and intake forms sent through the client portal (to your email). You will be expected to complete all of the forms by 3pm on the business day before your scheduled appointment. Meanwhile, our admin team will be verifying your insurance coverage and informing you of your financial responsibility before the appointment takes place. If you have any questions or want to follow up about the status of your new client form, you can contact us by email at admin@wholeheartedhc.org, or call/text us at 732-852-7373. In addition, if you’d like to follow along for practice updates and announcements, you can find us on Instagram at @wholeheartedhealingcollective

Family Member 1 First Name:(Required)

Family Member 1 Last Name:(Required)

Form completed by:(Required)

(first& last name)

Family Member 1 Gender(Required)

Family Member 1 Date of Birth:(Required)

Relationship to family(Required)

Family Member 1 Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(NOTE: your location at the time services are rendered is important due to licensing laws ; please specify if your home address is not in the same STATE as where you will be located during virtual appointments)

Family Member 1 Mobile Phone Number:(Required)

Family Member 1 Email address:(Required)

Email address will be used for your access to the client portal & appointment reminders.

Family Member # 2

Family Member 2 First Name:(Required)

Family Member 2 Last Name:(Required)

Family Member 2 Gender(Required)

Family Member 2 Date of Birth:(Required)

Relationship to family(Required)

Family Member 2 Home Address (if different than Family Member 1)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Member 2 Mobile Phone Number:(Required)

Family Member 2 Email address:(Required)

Email address will be used for your access to the client portal & appointment reminders.

Additional Family Members

Names and ages of additional family members

Type of counseling service(s) you'd like?(Required)

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Other

How did you hear about us?(Required)

If you were referred to us by a specific person, whether that is another provider or a loved one that is a client at WHC, please specify their name here.

Reason for seeking services?(Required)

Symptoms & concerns; please share as much as you feel comfortable sharing to help us match you with a therapist that can meet your needs.

What else would be important for us to know about your identity?

Race, culture, gender identity, sexual orientation, etc.

Are you comfortable with dogs?(Required)

No, I am not comfortable with dogs.

Yes, I am comfortable with dogs.

I am allergic to dogs.

Sometimes we have a pet dog in the office, but we have separate office spaces where no animals are allowed for those who aren’t comfortable or are allergic.

Therapist requested:(Required)

Please name any specific therapists on our team that you are most interested in seeing; or specify if you prefer a male or female, over 40 yrs old or under 40 yrs old; or any other preferences that you have. If you have no preferences, you can enter “n/a”

Insurance Type(Required)

(i.e. Aetna, Cigna, Horizon; write n/a if you don’t have insurance – if you have insurance please complete all relevant fields below) NOTE: we are NOT in-network with medicaid/NJ Family Care or Medicare)

Insurance Member ID #(Required)

(write n/a if you don’t have insurance)

Insurance Group #

Policy Holder's First & Last Name:(Required)

Which days and times are you available to schedule weekly appointments?(Required)

i.e. Mon or Thurs between 3pm-6pm Please offer at least a few times per week that could work for you.

Do you prefer telehealth or in-person?(Required)

In-person

Telehealth

A mix of both

Office is located in West Long Branch

Do you have any accessibility requirements you would like us to be aware of?

Are you comfortable with communicating about scheduling by email and/or text?(Required)

Text is best

Email is best

Both are fine

I prefer that you do not text or email me. Please call.

Please upload the front and back of your insurance card.

Drop files here or

Max. file size: 256 MB, Max. files: 4.

Please upload ALL adult family members' photo IDs & insurance policy holder's photo ID.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

New Client Registration Form – Family

Family Therapy

Family Member # 2

Additional Family Members

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