The Sandbox | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Reason for care

Why are you seeking therapy for yourself or your child?

Let us know any concerns you have or if there is more info you'd like to share.

Billing & Payment

Payment method

How do you plan to pay for appointments?

Insurance Details (we only accept BCBS, PEIA UMR, Peak)

Insurance Primary Holder NAME and DATE OF BIRTH (MM/DD/YYYY)

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Additional thoughts or questions

For example: what you'd like to focus on, insurance or payment questions, etc.

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.