New Client Evaluation

New Client Evaluation for potential Kuponya clients only

Please click HERE to read current policies. For Talkspace clients, and clients residing in Texas, do NOT complete this form.

Evaluations are reviewed during our normal business hours, Monday-Thursday 8AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.

First Name

Last Name

DOB (Serving ages 18-65; as stated under Policies).

Phone Number

What insurance do you carry? (Please take time to review home page for the plans we accept.)

Please provide a brief statement explaining why you are seeking treatment. If you have current, or previous, psychiatric diagnoses, please list them here:

Have you been hospitalized for psychiatric reasons? If yes, briefly indicate when, and why:

List current psychiatric medications.

List previous psychiatric medications.

We have received your submission. You will hear from us within one business day.

Kuponya

Telepsychiatry

Kuponya... - Swahili.... English translation, "healing; to heal"

New Client Evaluation for potential Kuponya clients only

Please click HERE to read current policies. For Talkspace clients, and clients residing in Texas, do NOT complete this form.

Evaluations are reviewed during our normal business hours, Monday-Thursday 8AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.

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New Client Evaluation for potential Kuponya clients only

Please click HERE to read current policies. For Talkspace clients, and clients residing in Texas, do NOT complete this form.

​

​

Evaluations are reviewed during our normal business hours, Monday-Thursday 8AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.