Embodied Practice, LLC | SimplePractice

Embodied Practice, LLC Send Message

Your info

First name

Last name

Phone

Reason for care

What brings you to therapy?

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Anxiety Complex Trauma/PTSD Interest in EMDR Therapy Interest in Somatic Therapy Relationship Challenges Drepression Grief Stress Management Other

Briefly describe any specific goals, needs, or preferences (optional):

Limited to 600 characters

Administrative

Referral source

Billing & Payment

Will you be utilizing insurance? If so, please provide which insurance company you have:

I am INN with most insurances including: Florida Blue/BCBS, United, Anthem, Aetna, Cigna, Oxford

Client Preferences

Preferred Days for Sessions

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Monday Tuesday Wednesday Thursday Any day Monday-Thursday (I am not in office on Fridays)

Preferred Times for Sessions

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Morning (9:00-11:00AM) Afternoon (12:00-3:00PM) Evening (4:00- 5:00PM) Please note: evening slots are bi-weekly only No preference Other

When is the ideal start date or timeline you are aiming for?

Within 1 month Within 2-3 months Flexible/whenever space is available

Preferred Session Format

In-Person Virtual Both In-Person & Virtual

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.