Inner Tide Counseling | SimplePractice

Inner Tide Counseling Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Phone number

Reason for care

What brings you to therapy at this time?

Have you been in therapy before?

Yes No Other

What are your main goals for therapy?

Are you currently experiencing thoughts of harming yourself or others?

If you or someone you know are in immediate danger, please call 911 or go to the nearest emergency room.

Yes No

Billing & Payment

Payment method

I accept HMAA, HMSA Quest, and HMSA PPO plans.

Client Preferences

Are you seeking in-person or telehealth sessions?

In-person in Hilo Telehealth

Are there cultural, religious, or identity factors you'd like your therapist to be aware of?

Do you need any accessibility accommodations?

What days are you available?

Current days available for scheduling are Mon-Thurs.

Monday Tuesday Wednesday Thursday

What times of day generally work for you?

Morning (9AM-12PM) Afternoon (12-3PM) Evening (3-6PM)

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.