Kate Berry Wellness | SimplePractice

Your info

First name

Last name

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Name you go by

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Reason for care

What’s bringing you to seek support right now?

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What kind of support are you looking for?

Individual Therapy Couples Counseling Discernment Counseling Not sure

Administrative

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?

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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.

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Do you consent to the use of AI in the delivery of your care?

Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

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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.