Book a Session

Who will participate?

IndividualOne person attending therapy Couples, family, or co-parentingTwo or more people attending

Email address for follow-up

Individual information

Full name exactly as listed on the insurance plan

Date of birth

Contact phone

Full address

Participant information

Enter the information below for every person who will participate in therapy.

Participant 1

Full name exactly as listed on the insurance plan

Date of birth

Contact phone

Full address

Participant 2

Full name exactly as listed on the insurance plan

Date of birth

Contact phone

Full address

Insurance

Bill insurance Do not bill insurance

Name of the one participant whose insurance will be billed

Policy name

Policy member ID

Days and times available for a telehealth appointment

What brings you to counseling?

I understand this preliminary request will be encrypted and stored in the private practice portal for Lisa’s review. This form is not monitored for emergencies; if I am in crisis, I will call or text 988 or call 911.

Your answers are encrypted and stored outside the public website. The notification email tells Lisa only that a new intake is waiting; it does not include your answers.

Requests are reviewed within 24–48 hours.

Participant 1

Participant 2

Participant

You don’t have to do this all on your own.