New Client Intake Form
This form is for FLORIDA residents only. To better serve you, please complete & submit the form below. Once your request is received, we will contact you directly to schedule an appointment. Please note that we do verify insurance prior to scheduling your appointment. You should hear back from our staff within 48-72 hours of submitting this form. We are currently not accepting Medicaid clients. if you would like to get added to our waitlist complete the information below. Please email admin@gabbycaresofsouthfl.com if you have any questions. Completion of this form asserts that you understand we do NOT provide consultations. Your appointment with your therapist will be your intake appointment. If you feel like your therapist is not a good fit after that appointment, we will be happy to match you with another therapist at Gabby Cares of South Florida or provide referrals to an outside provider.
First Name
Last Name
Today's Date
Email
Phone Number
Date of Birth
Your Age
Gender
Female
Male
Address
Please select billing type:
Insurance
Self-Pay
Insurance provider
Select an option
BCBS FL
United Healthcare
Optum
Florida Medicaid
Cigna
Oxford Health Plans
Aetna
EAP
Loveland/Open Path Voucher
Self-pay
Other
Insurance policy and group number
Desired Therapist
Gabrielle E. C. Johnson, Ph.D., LMHC
Brandi Herring, RMHCI
Preferred Therapist (if your 1st choice isn't available)*
Gabrielle E. C. Johnson, Ph.D., LMHC
Brandi Herring, RMHCI
Reason For Therapy (choose all that apply)*
Depression
PTSD
Sleeping Issues
Anxiety
Life Transition
Relationship Issues
Bipolar
Schizophrenia
Grief
Trauma
Cancer or other health issues
ADD/ADHD
Other
If you chose “other” above, briefly explain why
Insurance card (front copy)
Select a File
Insurance card (back copy)
Select a File
Please include any questions or concerns you may have here.
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You have reviewed & confirm the information being submitted is correct
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