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(217) 347-5118
info@thewellnessloft.com
408 S. 4th Street, Effingham, IL
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Philosophy
Services
Individual Therapy
Relationship Therapy
About us
Gallery
New Clients
Contact Us
The Wellness Loft New Client Form
New Client Form
Please populate all fields, if you don't have the answer, write
"NA"
Client Name
Pronouns
Email
Phone/Mobile
Parent / Guardian Name
What type of services are you seeking?
Individual Therapy
Couples Therapy
Child/Adolescent Therapy
Family Therapy
Please tell us what you are hoping to focus on in therapy:
Anxiety/Panic
Behavioral Issues (in children)
Body Image
Chronic Illness/Chronic Pain
Depression
Eating Disorder
Family Issues
Gender Identity
Grief/Loss
Life Transitions
Medical concerns/New medical diagnosis
Neurodiversity
Perinatal/Reproductive Support
Relationship Issues
Self-Exploration
Sex/Intimacy Concerns
Sexual Identity
Stress
Trauma/PTSD
Other
Specific Requests
Preferred Therapist(s)
If the therapist(s) you listed above is not available, are you open to working with a different therapist?
Yes
No
N/A
Payment Options
Insurance Company
Out-of-pocket
Insurance Company Name
Insurance Member ID
Phone/Mobile
Date of Birth (for insurance verification)
Type of Appointment
Telehealth only.
In-person only
Either telehealth or in-person
Which days of the week are you available for an appointment? (Choose all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Mornings (8am - 11am)
Yes
No
Afternoons (12pm - 4pm)
Yes
No
Evenings (5pm - 8pm)
Yes
No
about availability
How did you hear about The Wellness loft?
BCBS Provider Directory
EMDR Provider Directory
Facebook
Google
Instagram
Referred by a current/former Client
NARM Provider Directory
Psychology Today
Somatic Experiencing Provider Directory
United Healthcare Provider Directory
Walked/Drove by your office
Referred by another mental health or healthcare provider
reference
Submit
New Client Form Mobile
Client Name
Pronouns
Email
Phone/Mobile
Parent / Guardian Name (if the client is under 18 years old)
If under 18 years old, what is client's age?
What type of services are you seeking?
Individual Therapy
Couples Therapy
Child/Adolescent Therapy
Family Therapy
Please tell us what you are hoping to focus on in therapy:
Anxiety/Panic
Behavioral Issues (in children)
Body Image
Chronic Illness/Chronic Pain
Depression
Eating Disorder
Family Issues
Gender Identity
Grief/Loss
Life Transitions
Medical concerns/New medical diagnosis
Neurodiversity
Perinatal/Reproductive Support
Relationship Issues
Self-Exploration
Sex/Intimacy Concerns
Sexual Identity
Stress
Trauma/PTSD
Other
Specific Requests
Preferred Therapist(s)
If the therapist(s) you listed above is not available, are you open to working with a different therapist?
Yes
No
N/A
Payment Options
Insurance
Out-of-pocket
Insurance Company
Insurance Member ID
Phone/Mobile
Date of Birth (for insurance verification)
Type of Appointment
Telehealth only.
In-person only
Either telehealth or in-person
Which days of the week are you available for an appointment? (Choose all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Mornings (8am - 11am)
Yes
No
Afternoons (12pm - 4pm)
Yes
No
Evenings (5pm - 8pm)
Yes
No
Is there anything else you want us to know about your availability for appointments?
How did you hear about The Wellness loft?
BCBS Provider Directory
EMDR Provider Directory
Facebook
Google
Instagram
Referred by a current/former Client
NARM Provider Directory
Psychology Today
Somatic Experiencing Provider Directory
United Healthcare Provider Directory
Walked/Drove by your office
Referred by another mental health or healthcare provider
If you were referred by another mental health or healthcare provider, please provide their name
Submit
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