New Patient Intake Form (Therapy)

**Please scroll down for testing inquiry instructions**

First Name *

Preferred/Chosen Name

Last Name *

Pronouns

He/Him

She/Her

They/Them

Email *

Phone *

Date of birth *

Parent/Legal Guardian Full Name

Parent/Legal Guardian Phone Number

Location Preference *

Denver

Westminster

Telehealth

Are you seeking services because they are required or mandated in any way? *

Are you currently involved in a domestic violence situation? *

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 going to be using an HSA or FSA card for payments? *

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!

What therapy/coaching services is the client interested in? *

Individual Therapy

Couples Therapy

Family Therapy

ADHD Coaching

Group Therapy - Eating Disorder Process Group (18+)

Group Therapy - Binge Eating Disorder Process Group (18+)

Group Therapy - Relationships Therapy Group (18+)

Group Therapy - Womxn's Process Group (18+)

Group Therapy - Queer Process Group (18+)

Formal diagnoses *

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.

Insurance or Medicaid ID Number (Required for Medicaid) 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.

Insurance Card (Front) *

Please upload a photo of the front of your insurance card

Make sure that the photo is clear and ID numbers are visible. (This can be a screenshot)

Insurance Card (Back) *

Please upload a photo of the back of your insurance card

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.