Tandem Collaborative Wellness PLLC

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

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State

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Reason for care

What is the reason for seeking care?

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Which service type are you interested in?

Individual Therapy Couples Therapy ALS Wellness - for Persons living with ALS / Caregivers / Loved Ones Supervision for LCSWAs

Administrative

Referral source

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Billing & Payment

Payment method

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Insurance details

If you plan to use insurance, please upload a photo of your insurance card so we can verify your benefits ahead of your appointment. To complete verification, please provide the mailing address of the primary policyholder in the field below. Also, if the primary policy holder is not you, please also share their name, date of birth, and sex assigned at birth as we will need this to complete verification.

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Insurance card upload

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Client Preferences

Preferred clinician

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Is there anything that the practitioner needs to know?

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

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.