Natalie Heinz Counseling | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

What concerns are you or your child currently experiencing?

Please include frequency, length, and severity of concerns to help Natalie identify if you or your child would be a good fit.

Inquiry reason

Please check which of the following you would like Natalie to provide additional information about when returning your inquiry. If Natalie does not have immediate availability, she will provide you with a referral even if you are requesting to be added to the waitlist in order to ensure care for your needs.

I would like myself (or my child) to be added to the waitlist or be contacted about becoming a client when available. I have further questions about insurance and coverage. I would like to receive a referral for a provider with sooner availability. I have further questions about the waitlist or availability. I have further questions about therapy/specialities/treatment approaches. I have further questions about something else.

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

BCBS PPO UHC/Optum/UMR Aetna Caterpillar Network (BCBS CAT or UHC CAT) Cigna Private Pay/No Insurance Out of Network Insurance Other

Client Preferences

Natalie's openings are primarily in the mornings. Afternoon appointments are rarely open for new clients. No appointments are available for evenings or weekends.

I understand that appointments are held 9-5 Monday through Thursday and afternoon openings are rarely available. I agree to a morning appointment. I need an appointment that Natalie does not offer, and I would like referrals or have other questions.

Is there anything that the practitioner needs to know?

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

Limited to 600 characters

School attending or work of client

Please list the school your child attends (child client) or any current employer (adult client).

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.