Chelsea Thomas, Psy.D., LLC

Your info

First name

Last name

Phone

Name you go by

Is it okay for me to leave a voicemail?

I will follow up with you by phone

Yes Yes, but please keep it brief No

Billing & Payment

Do you plan to use insurance?

Yes No I'm not sure

If yes, who is your insurance provider?

Administrative

How did you hear about me?

I currently offer therapy through secure telehealth. Would virtual sessions work well for you?

Yes No I'm not sure

Reason for care

What brings you to therapy at this time

You’re welcome to share whatever feels most relevant. A few sentences is perfectly okay.

Limited to 600 characters

Do you have any questions for me? Or anything else you’d like me to know?

Limited to 600 characters

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.