Salam Therapy LLC | SimplePractice

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

Do we have your permission to contact you by text/SMS to coordinate a free 15-minute consult?

Note: Standard message and data rates may apply. This is ONLY for scheduling purposes.

Yes No

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Please provide your insurance provider and plan type (Medicaid, commercial, etc.) or indicate if you’ll be self‑paying, so we can coordinate benefits and keep therapy affordable.

Limited to 600 characters

Client Preferences

Is there anything that the practitioner needs to know for your initial 15 minute consult?

For example: what you'd like to focus on, insurance or payment questions, preferences regarding the clinician’s cultural background, religious perspective, language spoken, etc.

Limited to 600 characters

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.