Who is completing this form *

For Myself

For Someone Else

Prospective Client Legal Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please let us know your preferred way of being contacted *

Email

Phone

Text

How do you plan to pay for therapy? (current available options listed below) *

Private Pay (from $150)

Reduced Fee / Sliding Scale (from $50 with income verification)

Medicaid

Do you have medicare?

We are unable to accept medicaid if you also have medicare.

Yes

No

What kind of therapy are you seeking today? *

Individual

Group

Individual & Group

Which groups interest you the most?

Supporting Transgender Family and Friends (complete registration here - http://www.umbrellacollective.org/soffa-support)

Long-term Adult Online Therapy Group (Thursdays 5:30-7pm)

Clinical Consultation Group (TBD)

Have you seen a therapist at Umbrella Collective before? *

Yes

No

Check to add your email to subscribe to our listserv.

If you do not click the check box, you will not be added to our email listserv. You can come back to the website anytime to add yourself later.

Yes