Theragrace Application Client "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Client InformationFull Name*Date of Birth (MM/DD/YYYY) Phone NumberEmail Address Address Street Address City State / Province / Region ZIP / Postal Code Employment & Insurance Status Please select the option that best reflects your current situation and provide any relevant details: Currently Employed Previously Employed Not Currently Employed / Self-Employed / Other (For example: freelance work, side jobs, or employment without insurance coverage) Future Employment Employer NameExpected End Date (if applicable) Most Recent EmployerLast Day of Employment Please DescribeExpected Start Date Employer (if known)Do you currently have active health insurance? Yes No Insurance ProviderPolicy NumberExpected Date of New Coverage (if known) Therapy Services Therapist NamePractice NameEmail address of Therapist Telephone Number of TherapistPrior Session Frequency with Therapist Weekly Biweekly Monthly Other Please SpecifyPayment Agreement I understand that I may be responsible for $20 per session during the Theragrace program. Client InitialsConsent & Signature I agree to the terms and conditions set by Theragrace for the duration outlined in my contract. I understand that any sessions not completed within the designated timeframe will result in forfeiture of the remaining financial support.SignatureYour NameYour NameYour NameYour NameDate
