Hearts Landing Ranch | 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

Which of the following best describes your connection to military service? (Choose one)

I am currently a member of the military I am a veteran I am a spouse of military/veteran Dependent (under the age of 18) of military/veteran None of these apply

Zip Code of your Primary Residence?

Client Preferences

Is there anything that you have questions about or need us to know prior to moving forward with services?

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Is there a reason we cannot contact you or leave messages via the contact info given? If so, please explain why, and what the best contact information would be.

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If filling out for more than one person, please state relation, who is looking for services, and general reason for seeking care. (We will ask for more detail in the application)

For example: My son Micah, due to anxiety/depression or Both myself and my spouse for marital issues.

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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.