TheXponential PLLC | SimplePractice

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Consent for Contact (Pick ONE)

Please check the box below to confirm your understanding of the following (CHECK ONE):

By providing my contact information, I am giving my consent for TheXponential PLLC to contact me via those methods and leave a message if needed. I DECLINE to be contacted, so I will NOT be contacted even if I submit this form. I do not need to proceed with this form and can notify TheXponential PLLC directly with my questions.

Administrative

Referral source: How did you hear about us?

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

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'm not ready to schedule a consultation yet, but still want to submit this form. I will then email you (hello@thexponential.com) DIRECTLY with my inquiry. 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.

Billing & Payment

Are you planning to use your health insurance plan?

NOTE: We are only in-network with BCBS and Blue Choice PPO plans. Please contact your insurance company directly to confirm status and verify benefits.

Yes No

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

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

Client Preferences

Preferred clinician

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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.

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.

Reason for care

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

Limited to 600 characters

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.