Seasons Counseling, PLLC | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Preferred name

Date of birth

Reason for care

What is the reason for seeking care?

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Billing & Payment

Insurance details

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred Location

In-Person Charlottesville In-Person Culpeper In-Person Locust Grove In-Person Warrenton Telehealth

Is there anything that the practitioner needs to know?

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?

Seasons Counseling uses AI tools to generate session summaries, allowing our therapists to be fully present during therapy. Your information is protected by law under HIPAA. AI-assisted session summaries are manually reviewed by your clinician. Only information relevant to patient care is kept. All other information is discarded. AI does not make decisions about your care.

Yes No

Administrative

How did you hear about us?

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.