TheXponential PLLC | SimplePractice

Your info

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I'm Seeking:

Individual Therapy Couples Therapy Family Therapy I'm submitting on behalf of someone else Other

My Partner's/Other Person's Name

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My Partner's/Other Person's Email

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My Partner/Other Person's Phone

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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

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Limited to 600 characters

Billing & Payment

Are you planning to use your health insurance plan?

NOTE: We are in-network with Blue Cross Blue Shield PPO plans (including Horizon, Anthem, and FL Blue) and UChicago USHIP. Please call your insurance company directly to verify coverage and benefits using zip code ("60602" or "60610"), name ("Biyang Wang"), and company ("TheXponential PLLC").

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.)

Contact Attendance Policy

Please check the box below to indicate your agreement.

To change my appointment time, I need to notify TheXponential at least 24 hours in advance. If I provide delayed notice, or repeatedly cancel, future consultation requests will not be accepted. If I arrive more than 7 minutes after the scheduled time, my consultation will be automatically cancelled. Rescheduling is not guaranteed.

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.

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.

Technical Support

If you're experiencing technical or submission issues, please email us <hello@Thexponential.com> for assistance.

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.