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 Insurance Options * Anthem Blue Cross/Blue Shield Dean HealthPlan Quartz The Alliance Out of Network/Private Pay Insurance Member ID # For those using insurance, please provide your insurance member ID number 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 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!
