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Somatic Therapy Inquiry
Interested in somatic therapy? Reach out to us to start the conversation.
Somatic Therapy Intake
Name
*
First
Last
Email
*
Phone #
*
Date of Birth
*
MM slash DD slash YYYY
We ask for your date of birth to help expedite the verification process with insurance companies.
Insurance or Self Pay?
*
Anthem BCBS
Anthem Medicaid
Aetna
Cigna
Health Payment Systems
United Health Care / UMR
Self Pay
If your insurance is not listed here, we are not in your network. You can call your insurance company and inquire about any out of network benefits you might have. In order to work with us, you would need to be a self-pay client with the potential of being reimbursed by your insurance company. We are happy to supply Superbills.
Are you a WI resident?
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WI Resident
Out of State
Please be advised that our therapists can only see clients who reside within the state of Wisconsin.
What day(s) of the week work best for scheduling?
*
Monday
Tuesday
Wednesday
Thursday
Friday
No preference
What time(s) of day works best for scheduling? Please be advised that evening time appointments are limited. Please indicate if you have any daytime flexibility with your weekday schedule. Thank you.
*
Before Noon
Between 12-4pm
After 4pm
Please be advised that appointments scheduled for 4:00PM and later are booked well in advance by our existing clientele. Please consider how you can offer as much daytime availability on weekdays as possible to make it easier to get you on our books!
Do you have a preference between in person or telehealth therapy sessions?
*
In person only
Telehealth only
Mix of both
No preference
Are you interested in any other services Elle offers?
*
Nutrition for Eating Disorder Support
General Nutrition Needs
EMDR
Brainspotting
Somatic Therapy Group - The Anxiety Series
Body Acceptance Group
Grieve & Grow Support Group
Not at this time, thank you.
How did you hear about us?
*
Google
Facebook
Instagram
Psychology Today
From another publication on the web
From a family member or friend
From someone who works at Elle
From another healthcare provider
Other
Other comments
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