Ready to get started? Complete the form and our intake coordinator will be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Name of Potential Client If different than person completing this form First Name Last Name Potential Client DOB * MM DD YYYY Home Address * Email * Phone * (###) ### #### I'm looking for: * Individual Therapy Couples/Marriage Therapy Family Therapy Group Therapy Other Therapist Preference * By selecting your therapist preference, this supports our intake process. However, we cannot guarantee the preference. Nicole Carl (Accepting Virtual Clients) Sarah Strauss (Waitlist) Alexis Gade Nicole Krapf (Accepting Virtual Clients) Jeremy Pieper Emily Kotajarvi I don't have a therapist preference We have immediate virtual therapy appointments available. Are you open to telehealth sessions? * Telehealth works for me! I'm willing to wait a little longer for in-person, please! Insurance Options Dean HealthPlan Quartz Out of Network/Private Pay GHC The Alliance How can we help? * Briefly describe current symptoms/challenges Desired Outcome Briefly describe goals and hopes for therapy Modern Thrive Counseling is not a CCS provider. Are you in the CCS program? Yes No Do you have medicare? Yes No Do you have medicaid/BadgerCare/state sponsored plan? Yes No By completing this form, I am inquiring about MTC services. I understand that until all intake paperwork is completed and verified, I am not a current client nor under the care of a therapist with MTC. I understand How did you hear about us? * Thank you for your inquiry! We will be in touch as soon as possible. If you have not received a follow-up email within two business days, please email us at admin@modernthrivecounseling.com
