forms

We are glad you are taking the first step to feeling better.

If you are looking to request an appointment, you have made it to the right place! Please fill out as much as possible, and we will contact you within 48 hours. We will call you back to schedule a 15 min free consultation and set up an appointment.

Name of the Person Filing out the Form:

Relationship to the client:

Client name:

Birth Date:*

*The person receiving services must be 21 or older.

Zip Code:*

Please provide the zip code of your home.

Phone:

Email Address:*

What were you hoping to gain through the therapeutic experience?
Describe main concerns and goals

Language:*

What is your preferred language to do therapy?

Best time available:

Payor

Please Note: We only accept the following insurances: Cigna, Aetna, United Healthcare and Oscar (Not currently working with Medicaid).

If you are attempting to use insurance, please provide the member ID/policy #

IF NONE: Place N/A

Please add the 1800/1888 Provider number on the back of the insurance card

If you are not using insurance; please Skip.

We appreciate your reaching out to us!
Your well being is important to us, and we look forward to helping you feel better.

forms

We are glad you are taking the first step to feeling better.

QUICK LINKS

Support

Contact

Email: cecilia@connectingwithyouressence.com

Phone: (786) 618 - 2107

THE CLIENT PORTAL IS NOT TO BE USED FOR EMERGENCY SITUATIONS. IF YOU OR OTHERS ARE IN IMMEDIATE DANGER OR EXPERIENCING A MEDICAL EMERGENCY, CALL 911 IMMEDIATELY.

©2022 - Connecting with your Essence LLC. All right reserved

Information on this website represents the opinion of the Respective Author and is Protected Under the Laws of Copyright and Trademark.