The first step is reaching out

Fill out our secure contact form. Once received, our office will work to connect with you within a business day to answer any questions about counseling services, and if helpful, recommend a therapist on our team that best matches your needs. We look forward to helping you find a great fit!

First Name *

Last Name *

Birthdate *

MM/DD/YYYY

Phone *

Email *

Street Address *

City *

State *

Postal code *

By submitting this form, I consent to receive transactional messages related to my account or services I have requested from Optimum Joy, P.C. These messages may include appointment reminders, confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.

What has prompted you to want to start counseling? *

Therapist Preference *

Type of Therapy *

Please briefly describe your availability *

Please list at least 2 options

Location Preference *

Do you have a gender preference for the therapist you'll see? *

How did you hear about Optimum Joy? *

By whom were you referred?

Please include the name of the therapist, program, doctor, or person by whom you were referred.

Please share more information about the person who will join you in couples therapy:

Partner's First Name *

Partner's Last Name *

Partner's Birthdate *

MM/DD/YYYY

Partner's Email Address

Partner's Phone Number

Please provide more information about your child below, and list an optional email if your child is old enough to share any intake information via a new client form prior to their first session:

Child's First Name *

Child's Last Name *

Child's Birthdate *

Child's Email Address

Child's Phone Number

Do you plan on utilizing insurance?

Yes, I want to use my Insurance

No, I will be paying out-of-pocket

We will attempt to obtain a courtesy benefit check regarding your potential mental health coverage. Please provide the following:

Who is your insurance provider? *

What is the Member ID? *

What is the Group Number? *

Please attach a photo of both sides of your insurance ID card: *

Attach both FRONT and BACK copies

If you are not the primary subscriber on the plan, please provide all of the following information:

What is the subscriber's relationship to you?

i.e. parent, spouse, etc

Subscriber's Full Name

Subscriber's DOB

Subscriber's Phone

Subscriber's Address

Do any of these partnership programs apply to you? *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested from Optimum Joy, P.C.. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.tifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Thank you for submitting your answers, please hit submit once you are done.