Purple Change Wellness® | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Gender

State

Select the state you live in

Preferred Pronouns

Reason for care

Please describe the main reason you are seeking therapy right now.

What challenges are affecting your daily life, relationships, work, or emotional well-being? What would you hope is different six months from now if therapy is successful?

Limited to 600 characters

What have you already tried to address this concern?

What helped, and what didn't help?

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How ready do you feel to actively participate in the therapeutic process?

Rate on a scale of 0 (not ready at all) - 10 (completely ready).

Are there any factors that may affect your ability to participate in therapy?

Please share anything you believe would help us understand your situation, such as a recent crisis, substance use, major life stressor, financial barriers, scheduling changes, and/or support system limitations

Limited to 600 characters

Administrative

Which therapy format are you most interested in?

Please select all that apply.

Traditional weekly therapy Biweekly therapy Private-pay therapy intensives (extended sessions designed for focused and accelerated work) *Intensives are not covered by insurance and are offered as a private-pay service. I am open to discussing the options.

Referral source

How did you hear about Purple Change Wellness?

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Email address

Phone number

If there were an opportunity to make significant progress in a shorter period of time through an extended private-pay therapy intensive, how interested would you be?

Please choose one of the following:

Very interested Somewhat interested Unsure Not interested

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

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.