Get Started Form - The Gestalt Center

(720) 491-1142

First Name *

Last Name *

Email *

Can we send an email to this address?

Yes

No

Address (Street)

City

State

Zip Code

Your Phone Number

Date of Birth

Can we leave a voicemail at this number?

Yes

No

Do you prefer we follow up via phone call, text or email? (Select as many as you like)

Phone Call

Text Message

Email

Do you prefer in-person or virtual therapy? (Select as many as you like)

In-Person only

Virtual only

Open to Either/Both

Other

What brings you to therapy at this time? *

What dates and times would work best for you?

Our clinicians set their own days and times and knowing this can help us match you with the best fit. The more detail you can provide, the better.

Which of our services would you be interested in? (Select as many as you like)

Couples Therapy

Family Therapy

Individual – Child

Individual – Adult

Do you have insurance? If so, which of the following? (Select as many as you like)

If you have Medicaid, what is your Medicaid ID?

If you have Medicaid, do you also have secondary insurance (such as private insurance through an employer, a spouse, a parent, or Medicare)?

Yes

No

I don’t know

How did you hear about us?

** We’ll get back to you within 48 hours **