Goodlife Wellness Group New Patient
Who are these services for?
Adult
Child Under Age 18
Couple
Client First Name
Client Last Name
Client Birth Date:
Address
Phone Number
Email
Parent or Guardians
1) If Child is under 18 - Parent/Guardian Name:
Relationship to Child:
How did you hear about the practice?
60
INSURANCE TYPE
Medcost
Aetna
Aetna State Health Plan
Cigna
Blue Cross Blue Shield
UMR
Self Pay
United
Which time of day are you available to meet?
Daytime Only
Evening Only
Flexible day or evening
Which type of services are you looking for?
In Person Therapy
Telehealth Therapy
Group Therapy
Preferred Therapist
Nancy Smith
Mic Croitoru
No Preference
Tell us a little about how we can help (describe challenges and difficulties).
Submit
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