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Questionnaire

Hello, welcome.

Start your Journey

Please tell us how we can help you.

Individual, Family, or Couples Therapy

Select this if you would like to begin your journey towards individual, family, or couples therapy.

I am a provider

Select this if you would like to create an appointment for a patient.

Are you a Provider? Click Here.

If you have already registered through the patient portal, Click Here.

If you have any questions, reach out here.

Step 1 of 3

Start your journey.

Start your Journey

Fill out the entire questionnaire and take the first step.

The patient receiving these services is a minor (under the age of 18).

Patient's First Name *

Patient's Last Name *

Email *

Patient's Date of Birth *

^{12 years or older}

Guardian's First Name *

Guardian's Last Name *

Guardian's Date of Birth *

Phone *

* Required

Your Address *

Payment Method *

I have insurance, check eligibility

*Virginia Residents Only
Select this if you have an insurance provider and would like to check your eligibility immediately.

Self-pay

*US Residents
Select this if you plan to pay out of pocket.

If you have any questions, reach out here.

Lets check your eligibility.

Insurance Provider *

Member/Subscriber ID *

Group/Plan ID *

I acknowledge that I must be a resident of the State of Virginia in order to use my insurance for services.

Check this box if you do not have your insurance information on hand and will upload it manually later on before your first session.

Submit and Continue Submit and Continue

Thank you. Your information was received. Please continue with the form.

Your insurance information may be sent to our trusted third party for validation. If you have any questions, reach out here.

Step 2 of 3

How can we help?

How can we help you?

I'm feeling depressed or down

Helping you to protect all your digital activity and data

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I recently lost a family member or friend

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I’m having difficulties managing my stress or anger

Helping you to protect all your digital activity and data

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I have a mental health diagnosis, and I’m trying to navigate it

Helping you to protect all your digital activity and data

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I am more anxious than normal

Helping you to protect all your digital activity and data

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My mood is constantly fluctuating

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I am dealing with substance use

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Other

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What gender do you identify with?

Have you been in therapy before?

What gender would prefer for your therapist?

Which type of therapy are you interested in?

If you have any questions, reach out here.

Step 3 of 3

Select pricing plan

Answer just a few more questions.

1. Have you been diagnosed with a mental health disorder, and if so, what is it?

2. What are your goals for therapy?

Helping you to protect all your digital activity and data from unwanted party

3. Are there any religious or spiritual practices that are important to you in the context of your healthcare?

4. What are your fears about therapy?

Helping you to protect all your digital activity and data from unwanted party

$8

/month

Basic Plan

Billed annually, yearly.

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$16

/month

Pro Plan

Billed annually, yearly.

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Thanks, your submission has been received. Please check your email shortly to see if you are eligible and other important details from the sanctYOUary team.

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