Woods Counseling Services | SimplePractice

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

Select the state you live in

Administrative

Referral source

How you were referred to us?

Google Search Online Directory (Psychology Today) I was referred by a healthcare provider I was referred by a friend/family member Other

I typically recommend starting with weekly sessions and then tapering off to every 2 weeks, then monthly. Are you able to commit to this at this time?

Yes No

I approve Woods Counseling Services to contact me via call/text on the phone number provided.

Yes No

Billing & Payment

Will you be using insurance or paying out of pocket?

Please note: I can only accept Blue Cross Blue Shield for Louisiana residents. If you have an out-of-state BCBS plan, you may still be able to use your insurance, but we will need to discuss this. Also, I cannot bill insurance for couples therapy. If you have concerns about payment or insurance coverage, let me know, and we can talk through your options.

Yes, I have Blue Cross Blue Shield and live in Louisiana (Individual Sessions Only) No, I plan to pay out of pocket I need to talk to you about this I plan on submitting my receipts to insurance for reimbursement

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Is there anything that we need to know?

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

Limited to 600 characters

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

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. You also agree not to submit any payment information, including credit or debit card details, through this form.