PRO TIP: Take Pictures of Drivers License/ID (front & back) & Health Insurance Card/s (front & back) BEFORE filling out this form.
For all *Prospect Clients and Returning Clients, this 5-7 minute form assists us in understanding your treatment needs, ensuring an optimal client-clinician match. It also captures your scheduling preferences. Kindly complete and submit this form, and we'll swiftly provide you with a **Benefits Quote** and arrange your Intake Session based on your preferences.
What's the Next Step?
You'll receive a Welcome Message with:
Your Intake Appointment Details
Benefits Quote or "Good Faith" Estimate
To confirm the Intake Appointment, simply reply with "C".
It's that easy to schedule with me!
Melissa E. Mendoza, LMSW
🔗LinkTree Link: https://linktr.ee/pinkpsy
*If not a match we will provide referrals.
**No obligation or cancellation fees if you decide not to proceed with the session based on the provided benefits quote.
***All Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant and ENCRYPTED which means your information is safe and secure.