Spectrum Psychology Inc | SimplePractice

Spectrum Psychology Inc Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

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Street Address

City

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Race/Ethnicity

American Indian or Alaska Native Asian Black or African American Hispanic, Latino/a/x, or of Spanish origin Middle Eastern or North African (MENA) Native Hawaiian or Other Pacific Islander White Another race/ethnicity not listed Prefer not to say

Reason for care

Which type(s) of care are you seeking support for?

Psychological Assessment/Evaluation Psychotherapy Coaching Medication Management Groups Retreats Other

Administrative

Are you currently experiencing housing insecurity or other urgent needs?

Yes No

Do you have health insurance?

If you have health insurance, please include your provider and plan number here. If not, please answer "no."

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Do you have out-of-network coverage?

Yes No

Do you have a Health Savings Account (HSA) plan?

Yes No

What is your current household income (before taxes)?

Less than $25,000 $25,000-$50,000 $50,000-$75,000 $75,000-$100,000 Over $100,000

Number of people supported by this income

Do you currently receive any of the following?

Medicaid Medicare SSDI/SSi SNAP/Food Assistance Housing Assistance None

Is there anything else you would like for us to know as we review your application?

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Want to stay in the loop about new neurodivergent-affirming resources, reduced-fee openings, and community offerings? We send occasional updates (no spam, and you can unsubscribe anytime).

Yes, please add me. No thanks.

Attestation Statement

I confirm that the information I’ve provided is true to the best of my knowledge, and that I am applying in good faith.

What reduced-fee rate are you hoping for? (or a range)

$50-$100/session $101-$150/session $151-$200/session $201-250/session $250+/session

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.