Alliance Counseling Works | SimplePractice

Alliance Counseling Works Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Add a short description to help match you with the right provider.

What kind of care is being sought?

Psychotherapy (individual, couples, family) Medication Management Intensive Outpatient Program (IOP) Testing & Evaluations (ADHD, Bariatric, etc)

Billing & Payment

Payment method

How do you plan to pay?

Insurance details (If Out Of Pocket, type "None")

Type Primary Insurance holders info (Name, DOB, Insurance Carrier, Member ID)

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Choose which locations you are willing to attend.

See www.alliancecounselingworks.com for locations

Round Rock Westinghouse Rd Cedar Park Kyle South Austin Cypress Telehealth Only

Who would you like to see? * Therapists only work at one location* (see www.alliancecounselingworks.com for a list of therapists by location)

You can also type "No Preference"

Administrative

If the client is a minor, are parents separated?

Type "N/A" If client is not a minor

If client is a minor AND parents are seperated, can you provide a legal document confirming the Independent Right to Consent to Treatment? (ie. Custody Agreement, Divorce Decree, ect.)

"Yes / No". (you'll be able to upload later if needed)

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.