Please complete the brief intake questions below and you’ll be contacted by our Intake Coordinator Dr. KC Berto within 24 hours to schedule a brief assessment (30 minutes). Our assessment ensures that we fully understand your request for services and enables us to connect you with the MPA clinician best suited for your interests and needs. The initial assessment also provides your new therapist with a profile summary and initial treatment recommendations. This helps set you up for success and supports a more streamlined start for your therapy at MPA. The Initial Assessment cost is $150. Please note, all clinicians at MPA are PRIVATE PAY ONLY and not in-network with insurance providers. Payment is expected at the time of service. All clinicians are able to provide a superbill, which is a medical receipt that requires a diagnosis and may be used with insurance providers to submit for any out-of-network reimbursement you may qualify for after meeting your deductible. If you’d like to see an MPA Clinician, we recommend you call your insurance company in advance to verify your deductible and understand at what rate you may be reimbursed for out-of-network benefits. If you require services from an in-network provider, please visit your insurance company website and identify local resources. *

I understand.

Name *

First Name

Last Name

Phone *

(###)

###

####

Are you in crisis? *

If you are in crisis, or someone you care about is in a crisis, and you would like to talk to a trained professional immediately, please call the Georgia Crisis and Access Line at 1-800-715-4225.

Yes

No

What type of therapy are you interested in? *

Select all that apply.

Individual Therapy

Couples Therapy

Family Therapy

What type of sessions would you prefer? *

In-person

Virtual telehealth

Either / No preference

When are you available for sessions? *

Select all that apply.

Weekdays 9 AM - 3 PM

Weekdays 4 PM - 7 PM

Weekends

Have you been in therapy before? *

Yes

No

Are you currently taking any psychiatric medications and/or working with a psychiatrist? *

Yes

No

May we thank this referral?

Yes

No

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