West Shore Wellness, LLC | SimplePractice

West Shore Wellness, LLC 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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Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

Are you seeking care for yourself or someone else?

Myself My Child - 5 or Under My Child - 5-12yo My Adolescent - 13-18yo My Young Adult - 19yo + My Spouse / Partner Myself and My Spouse / Partner Myself and a Family Member

Administrative

Inquiry reason

Referral source

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Billing & Payment

Insurance details

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Insurance card upload

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Client Preferences

Preferred appointment times

Morning Afternoon Evening Monday - Anytime Tuesday - Anytime Wednesday - Anytime Thursday - Anytime

Preferred clinician

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For example: what you'd like to focus on, insurance or payment questions, etc.

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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.