Ticum Therapy | 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

Sex at birth

For insurance verification

State

Select the state you live in

What language(s) do you speak

(If you are requesting for a child please choose the language(s) they speak)

English Spanish Portuguese Other

If you are making this request on behalf of your child what languages(s) do you speak as their parent or guardian

(Don't answer this question if you are not requesting on behalf someone else)

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Address:

Relationship Status

Employment Status

(You can select multiple options)

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

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