TheXponential PLLC | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

State

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In which city?

OR if the location was not listed above, please indicate below.

My Partner's/Other Person's Email

If Applicable for Couples/Family Therapy, Or the Person You're Requesting on Behalf of

My Partner/Other Person's Phone

If Applicable for Couples/Family Therapy, Or the Person You're Requesting on Behalf of

Privacy and Confidentiality Agreement

Please check the box below to confirm that you (the Client/Patient) understand and agree to the following statement:

All content that I (the Client/Patient) disclose to TheXponential PLLC, which may contain personal, confidential, and identifying information, will be stored and used to respond to my inquiry. I am responsible for ensuring that the sensitivity level and contents of disclosure match my comfort level and intended purposes.

Client Preferences

Preferred clinician

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Reason for care

Inquiry Reason (PLEASE READ CAREFULLY!):

Why are you filling out this form? (NOTE: This will determine whether our office or a clinician will contact you DIRECTLY/ SEPARATELY after you submit this form.)

I will schedule a consultation using the LINK to be provided in the CONFIRMATION EMAIL upon submitting this form. I understand that a clinician will NOT contact me separately. I am visiting TheXponential's, or a 3rd-party referral website. I've read all available information but still have questions. I DO WANT TheXponential to contact me SEPARATELY after I submit this. OOPS! I am a healthcare provider/organization, NOT a prospective client. INSTEAD OF continuing here, I will email TheXponential (hello@thexponential.com) DIRECTLY with my inquiry. OOPS! I have a NON-THERAPY inquiry and should fill out a DIFFERENT form (www.thexponential.com/contact). I will leave this form. I will visit your website, and/or email you (hello@thexponential.com) DIRECTLY for information.

Please provide a brief summary of your Reason(s) for seeking services (5-6 sentences MAX please):

Limited to 600 characters

Are you planning to use your health insurance plan?

NOTE: We are only in-network with BCBS PPO, Blue Choice PPO, and USHIP plans. Your BC/BS plan type may be under a different name. Please contact your insurance company directly to confirm status and verify benefits.

Yes Yes but you're Out-Of-Network No - I will Private Pay/ Self Pay

If you answered yes to using health insurance, please name the type of plan

(i.e. Blue Cross, Anthem, Blue Cross Blue Shield of Illinois, Blue Choice, PPO plan)

Administrative

Where did you hear about our practice?

(Psychology Today, Google Search, Asian Mental Health Collective, www.thexponential.com, other healthcare provider, News/Media, Insurance Plan, AI, etc.)

Submission Agreement

Please check the bow below to indicate that you (the Client/Patient) understand and agree that:

Submitting this form does not establish a patient-therapist relationship, and should not be interpreted as medical or mental health care. A response to this inquiry does not indicate or guarantee availability of TheXponential PLLC's services or providers. Follow-ups and initial consultations only serve to assess the fit and logistics of using TheXponential's services in the future.

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GDPR Agreement

Please check to box below to indicate your understanding and consent.

I (Client) consent to having this website store my submitted information so that TheXponential PLLC, their Business Associates and Website Partners can respond to my inquiry.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.