Asheville DBT & Trauma | SimplePractice

Demographics

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Your info

First name

Last name

Phone

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

What is the client's preferred name, or name they go by?

If you are filling out this form for a minor, please put the name of the legal guardian here.

If you are filling out this form for a minor, please tell us what school district you are in:

After receiving your contact inquiry, we will EMAIL you within 48 business hours to schedule your appointment and send you important electronic paperwork. Please keep an eye on your email after submitting this form.

I understand that I will be contacted via email

What are your preferred pronouns?

(she/her, he/his, they, them, etc.)

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.