We know the importance of having the right provider from the beginning of your therapy experience. By answering the questions below, we’ll be able to best match you with a therapist who is best suited to your child's and family needs and support the process of beginning therapy. This is a HIPAA-compliant, secure form. We value your privacy, and access to your questionnaire is limited to our Client Care Manager and pertinent clinical staff of PLAE. If you are in a crisis or if any other person may be in danger. Please call 911 or go to the nearest emergency room. Or, use the crisis resources below: National Crisis Hotline - dial 988 National Text Crisis Hotline - text 988 or 741-741 Utah Warm line (you are not in crisis, but would like to talk to someone now): 801-587-1055

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Client Name

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Client Date of Birth

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PLAE is an out-of-pocket clinic, meaning we do not work directly with insurances nor Medicare. However, many of our clients seek reimbursement from their insurances, and we can provide statements to you if this is something you are interested in. You can see if you have out-of-network coverage by logging into your insurance company’s website or calling the number on the back of your card. For therapy services, the first step in our specialty care is a 60-minute Diagnostic Assessment (referred to as an "Intake") which is $275. After intake, 45-minute sessions are $160. For more information, please visit our website's Services tab: https://www.plaetherapy.com/our-services-payment. Please keep in mind that these are our 2024 rates.

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