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Name *

First Name

Last Name

Phone *

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Partners Name

For couples therapy only

First Name

Last Name

Partners Phone

For couples therapy only

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Preferred method of communication *

Phone

Text

Email

Out of Network Insurance Acknowledgement *

My-Therapist is an Out-of-Network Insurance provider. Please click below to acknowledge that we do not submit claims to insurance. We are able to provide you with a superbill that you can submit for out of network reimbursement. *

I Acknowledge

Email and Text Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to My-Therapist, Inc. therapists and/or office staff communicating with me via email or text message. DISCLAIMER:By providing my phone number to My-Therapist, Inc., I agree and acknowledge that My-Therapist, Inc. may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled please see our privacy policy below: PRIVACY POLICY:No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

I Consent