Queen Village Therapy Group

Queen Village Therapy Group 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

Sex at birth

For insurance verification

What state do you live in?

Our licensing boards require that therapists only see clients who are physically in a state where they hold a license during sessions, even if the session is virtual.

Reason for care

What’s bringing you to therapy right now?

Limited to 600 characters

Type of Service

Please Note: Our therapists are currently only able to offer virtual sessions at this time.

Individual Therapy Couples Therapy Family Therapy EMDR ESA Evaluation

Administrative

Do you have any questions you would like our administrative team to follow up with you about?

Questions about insurance, fees, or payment options Help finding the right therapist for me (or my child/family) Scheduling or appointment availability Questions about getting started (intake, paperwork, what to expect) Questions about virtual sessions (telehealth)

How did you hear about Queen Village Therapy Group?

Billing & Payment

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Times you’re typically available:

Morning (8am-10am) Late Morning (10am-12pm) Midday (12pm-2pm) Afternoon (2pm-4pm) Late Afternoon (4pm-6pm) Evening (6pm-8pm)

Days you’re typically available:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you have a preference for your therapist’s background or identity?

No preference Female Male LGBTQ+ BIPOC

Preferred Therapist

Is there anything else you’d like us to know to help us find your best match?

For example: preferred session frequency, therapist style, or anyone you’d prefer not to be matched with.

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.