New Patient Intake Form | Healing Arts & Wellness

Step 1 of 6

Who needs support?

This helps us match you with a therapist who specializes in working with your specific age group and situation.

👶 Child (Under 12)

🎒 Teen (13–17)

🧑 Adult (18–64)

🧓 Adulto mayor (65+)

💑 Pareja

👨‍👩‍👧 Familia

Step 2 of 6

What would you like to work on?

Select all that apply. Your clinician will review these before your first session.

Step 3 of 6

How would you like to meet?

We offer in-person sessions at our West Palm Beach office and telehealth sessions anywhere in Florida.

🏢 En Persona WPB Office

💻 Virtual Telehealth FL

🔀 No Preference Either works

Step 4 of 6

What is your insurance?

We are in-network with major carriers. We'll verify your benefits for free before your first session.

Select Your Insurance Plan

Member ID (Optional — We can look it up)

💡 We verify for free. Once you submit this form, our billing team will call your insurer directly and confirm your exact copay and coverage before your first appointment. No surprises.

Step 5 of 6

¿Qué horario le funciona mejor?

Select your preferred days and times. We'll do our best to match your schedule.

Preferred Time of Day

🌅 Mañana8 AM – 12 PM

☀️ Tarde12 – 5 PM

🌙 Noche5 – 8 PM

How soon do you need to be seen?

Step 6 of 6

Almost done — your contact information

We use this to confirm your appointment and verify your insurance. All information is encrypted and HIPAA-secure.

Nombre *

Apellido *

Número de teléfono *

Correo electrónico *

Date of Birth

Idioma Preferido

Anything else you'd like us to know? (Optional)

🔒 Your privacy is protected. This form is transmitted using encryption. Your information will only be used to match you with a therapist and verify your insurance. We never sell or share your data. By submitting, you agree to our Política de Privacidad y Aviso HIPAA.

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Thank You! We'll Be in Touch Soon

Your intake form has been received. A member of our team will call you within 1 business day to confirm your appointment and review your insurance coverage.

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Need to reach us sooner?

(561) 787-9494

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Our Office

4300 Miller Ave, West Palm Beach, FL 33405

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New Patient Intake Form — Healing Arts & Wellness