Julie "Jaye" Williams | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Date of birth

What sex is on your insurance policy?

For insurance verification

Reason for care

BRIEFLY state your reason for seeking therapy at this time. (You will be asked for more detail on the intake form sent after appointment approval)

Be brief on this initial screener. One to two sentences.

Limited to 600 characters

Billing & Payment

Payment method

Will you be using insurance, or paying out of pocket? (Very Important: There are some instances that insurance may not cover costs of behavioral health services, even after verifying coverage. Please be advised that cost for services remain the responsibility of the client/patient until insurance processes claim at the expected contract rate. At this time, I only accept Lyra Health and Optum EAP programs. Feel free to move forward using any of the insurances listed below.

Client Preferences

If your requested time is no longer available, please let me know what you would like to do.

Please offer me the next available appointment. Please provide me with a referral to someone else. I will proceed with finding someone else at this time.

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

If you have additional questions that you would like answered prior to moving forward with confirming your appointment, please provide your question here. I will respond via the client portal within 24-28 business hours via email.

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.