Ally Neuman, LCSW - Strengthening Connections Within and Between
Your Name (please include your spouse/partner's information in this form if you are interested in couples therapy)
Phone Number and E-mail Address
Home Address
Date of Birth
Your Insurance Plan Name, Member ID and Group # (complete only if you are interested in using your insurance plan to cover therapy services).
Employer/School Name
Contact Information for Providers (on the back of your insurance card)
Emergency Contact Information
Referral Source (who can I thank for recommending me)
Please tell me a little about the concerns you are hoping to work on in therapy at this time (optional)