Become a Client Today | Leek Therapy

Client Profile Form

Client Information

Client First Name *

Client Last Name *

Preferred Name

Client Phone Number *

Client Email Address *

Client Gender

Male

Female

Non-Binary or Transgender

Is the Client a Minor?

Yes

No

If client is school aged, what school district are they enrolled with?

Date of Birth *

Age *

Other Pronouns

Pronouns

He/Him

She/Her

They/Them

Other

Contact Information (if different from client)

Contact's First Name

Contact's Last Name

Contact Phone Number

Contact's Email

If you are contacting on behalf of the client, have they agreed to therapy?

Yes

No

I’m waiting to find a therapist before speaking with the client

Therapy is mandated by court of legal authority

Please Type Other Reason Here

Therapist you are requesting to see:

Client's Availability for Sessions (choose all the apply) *

Please specify other time here

Please Specify Other Insurance here

Other Insurance Carrier

Anything else we should know?

Would you like us to verify your insurance now?

Yes

No

Insurance Company Listed on Your Card

Member ID#

Plan (if you see it on your card)

Group Number (if you see it on your card)

First Name (EXACTLY as it appears on your card)

Middle Name or Initial (EXACTLY as it appears on our card)

Last Name (EXACTLY as it appears on your card)

Name and DOB of CARD HOLDER (if not self)

Upload a Picture of the Front of your Card (preferred but not necessary)

Upload a Picture of the Back of your Card (preferred but not necessary)

If you have any questions or issues completing this form, please contact [email protected] for assistance.