Creative Wellbeings, PLLC | 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

Sex at birth

For insurance verification

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Pregnancy Postpartum issues Relationship issues Sexual health Substance use Trauma Other

What type of therapy and modalities are you mainly interested in?

(Check all that apply)

Individual Therapy Relationship Therapy Group Therapy Sex Therapy Sex Education Art Therapy EMDR and Trauma therapies Outdoor Nature Based Therapy Pregnancy-Postpartum Support I’m not sure yet

Let us know how we can help you and what services you are seeking:

Please be specific as possible while still honoring your comfort level.

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If you are in a relationship, has someone in the relationship suggested separation?

Yes No Maybe

Jenn's primary therapeutic focus is sex therapy. Are you looking for sex therapy services?

She does take on non-sex therapy cases as well

Yes No Maybe

Administrative

Referral source

Enter how you were referred to our services

Client Preferences

Preferred appointment times:

The times listed below are Jenn’s general availability. This does not mean that all the times below are available at this time, so please check all the times that could work for you. THERE IS NO AVAILABILITY PAST 2pm OR ON WEEKENDS.

Tuesday mornings Tuesdays afternoons Thursday mornings Thursday afternoons Friday mornings Friday afternoons

Do you understand that we do not accept insurance?

Jenn is an Out of Network (OON) provider. This means she does not take insurance. We are happy to provide a superbill for you to submit for reimbursement from your insurance company. You are 100% responsible for communication with your insurance company to determine if they cover Out-of-Network providers. It is important to make sure that you specifically make sure they cover Licensed Marriage and Family Therapists (Washington). We do not offer superbills for relationship therapy. The fee for a 50-min individual session is $205 and $230 for relationships, and it is due at the time of session. Would you like to proceed? The fee for a 80-min individual session is $280 and $305 for relationships.

Yes No

Do you understand that if you are reaching out for services, your initial video chat consultation is $30 for a 20 minutes? Paperwork must be completed at least 48 hours prior to your video call to avoid cancellation. Please note you may be charged the full session fee if you late cancel (less than 48 hours notice) or no-show.

Yes No

Are you willing to be placed on a waitlist if we are not accepting new clients?

Yes No

Is there anything that the practitioner needs to know?

For example: payment questions, scheduling questions, etc.

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.