Ready to get started? Complete the form and our intake coordinator will be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Name of Potential Client If different than person completing this form First Name Last Name Potential Client DOB * MM DD YYYY Home Address * Email * Phone * (###) ### #### I'm looking to: * Schedule an intake appointment Learn more about MTC services Attend an event or group Reset portal password (current clients only) Other I'm looking for: Individual Therapy Couples/Marriage Therapy Family Therapy Group Therapy Other Therapist Preference By selecting your therapist preference, this supports our intake process. However, we cannot guarantee the preference. Nicole Carl Sarah Strauss (Waitlist) Karoline Walls Alexis Gade (Waitlist) Nicole Krapf (Waitlist) Jeremy Pieper (Waitlist) Amy Harvat (Waitlist) Emily Kotajarvi I don't have a therapist preference We are a teaching clinic and currently have two clinical mental health interns who are accepting clients at a reduced rate. Each clinical intern has completed their training and are under the supervision of Amy Harvat. Our clinical interns are expected to provide the same level of care as licensed providers. I'm interested in working with a clinical mental health intern at a reduced rate. I'm not interested at this time. Insurance Options Dean HealthPlan Quartz Out of Network/Private Pay How can we help? * Briefly describe current symptoms/challenges Desired Outcome Briefly describe goals and hopes for therapy How did you hear about us? * Modern Thrive Counseling Website Google Search Psychology Today Recommended by a friend Referred by healthcare provider Other Modern Thrive Counseling is not a CCS provider. Are you in the CCS program? Yes No Do you have medicare? Yes No Do you have medicaid/BadgerCare/state sponsored plan? Yes No By completing this form, I am inquiring about MTC services. I understand that until all intake paperwork is completed and verified, I am not a current client nor under the care of a therapist with MTC. I understand Thank you!
