New Patient Intake Form (Therapy)

Are you seeking services because they are required or mandated in any way?
Are you currently involved in a domestic violence situation?
What is your risk of harming self?
Are you willing to put a credit or debit card on file?
It is the organization's policy to have a card on file. Even if it will not be charged (includes Medicaid clients)
Are you located in Colorado?
Are you a previous client with Aspen Ridge Mental Health (CTAC)?
If "yes," and you are having troubles signing up with us again, please email us!
Please let us know if you are formally diagnosed with any of the following disorders
Primary Insurance for Services
Our base rate for out of network therapy services start at $225 for the first appointment and $175 for each appointment after that.
Secondary Insurance for Services
We cannot accept CO Medicaid when active in conjunction with another form of insurance.
Medicaid will be verified before your appointment is accepted. It will be canceled if we see that you do not have a Medicaid we can accept.
Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)
Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)

I agree to terms & conditions provided by the company. By providing my information, I agree to receive follow up messages from the organization.