Matthew Kelsey | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

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Phone

Name you go by

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Administrative

How did you hear about us?

What are you contacting the practice about?

Client Preferences

What brings you to the practice, and what are you hoping for?

A brief description is enough. You do not need to provide your full history or upload records at this stage.

Limited to 600 characters

For evaluation inquiries, who is requesting or referring the evaluation?

Is there a deadline or time-sensitive date we should know about?

For example, a claim deadline, hearing date, return-to-work date, or other required completion date.

Reason for care

Kelsey Psychological Services is a private-pay practice and does not bill insurance directly. Are you comfortable proceeding on that basis?

Yes I have questions about fees or payment

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.