Name of person completing this form *

First Name

Last Name

Name (if services are for a minor)

First Name

Last Name

Phone Number *

(###)

###

####

Preferred Contact Method *

Please let us know your preferred contact method.

Email

Phone Call

Text

Insurance *

Will you be using insurance? IHCC is in-network with the following:

BlueCross BlueShield of Texas

UnitedHealth

Aetna

Self-Pay

What services are you interested in? *

Individual Services (EMDR, CBT, trauma)

Play Therapy

Parent-Child Interaction Therapy (PCIT)

Waiting List Disclaimer *

Waitlist Disclaimer: Being placed on the waiting list is not a guarantee of services. Once an appointment becomes available, a therapist will contact you to discuss the requested services and determine if it is within the scope of what our practice can offer. If the services are for a minor and any custody paperwork and/or a divorce decree is in place, IHCC will need the most recent copy in the file prior to the first appointment. We cannot provide any recommendations for access, possession, nor custody of a minor child to any person nor professional.

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