Kate Berry Wellness | SimplePractice

Kate Berry Wellness Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What’s bringing you to seek support right now?

Limited to 600 characters

What kind of support are you looking for?

Individual Therapy Couples Counseling Discernment Counseling Not sure

What kinds of mental health support or treatment are you currently receiving, or have accessed in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past Currently in couples therapy Couples therapy in the past None of these apply

Administrative

Inquiry reason

Referral source

How did you hear about me?

Would you like to be added to my mailing list and receive (very) periodic newsletters with mental health tips, insights, community resources, and upcoming offerings?

Yes, please No, thank you

Billing & Payment

Insurance Carrier

Please note that I do not bill insurance for couples services, and offer that as private pay only

Aetna Allegiance Blue Cross Blue Shield Cigna HMK Mountain Health Coop Boulder Administrative Services EBMS Private pay Other

Client Preferences

Preferred appointment times

My office hours 9 am to 5 pm Tuesday-Thursday, with bi-weekly availability on Fridays.

Tuesday mornings Tuesday afternoons Wednesday mornings Wednesday afternoons Thursday mornings Thursday afternoons Friday mornings

Preferred meeting location

Is there anything else you think I should know, or any other questions you have?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.