Getting Started

Shopping Cart

Your Cart is Empty

Quantity:

Subtotal

Taxes

Shipping

Total

Introspection & Reflection LLC

"Change that comes from within"
Daysha Phimphone LPC,LPN,CCATP

GETTING STARTED

IMPORTANT INFORMATION:

* PLEASE LEAVE YOUR EMAIL ADDRESS AND PHONE NUMBER OR WE WILL NOT BE ABLE TO CONTACT YOU.

* PLEASE DO NOT LEAVE THE CONTACT INFORMATION SECTION BLANK. WE CANNOT CONTACT ANYONE WITHOUT AN EMAIL ADDRESS OR PHONE NUMBER.

* PLEASE INPUT YOUR INSURANCE MEMBER ID ON THE FORM OR YOUR FORM WILL BE INCOMPLETE. After insurance verification, we will contact you if your plan includes a deductible to meet or co-payment for sessions.

* Please note we will review your request, however, we may not be able to accommodate every request. Request are subject to approval for ALL THERAPIST.

* After you complete this form, you will be sent consents forms electronically from our platform THERAPLATFORM that MUST be signed before you may proceed with services.

* After completion of consents, a therapist will reach out to you to schedule an intake assessment. When intake is complete, your assigned therapist will reach out at their earliest convenience to schedule an appointment to begin psychotherapy.

If you have any questions, please feel free to reach out to us at 912-737-2176.*

FIRST NAME*

LAST NAME*

DATE OF BIRTH*

PARENT/GUARDIAN NAME ( IF APPLICABLE)

PHONE*

EMAIL ADDRESS*

STREET ADDRESS*

CITY *

STATE*

ZIP CODE*

GENDER*

PREFERRED THERAPIST*

Please note we will review your request, however, we may not be able to accommodate every request. Request are subject to approval and recommendation for ALL THERAPIST.

SERVICE LOCATION*

Please select where you would prefer to have your visits. Please note if you select 'telehealth', you may be assigned to a therapist who can not accommodate future office/in-person visits. If you would like to have both office and telehealth visits please select 'both'.

INSURANCE/METHOD OF PAYMENT *

IF YOU DO NOT SEE YOUR INSURANCE LISTED, THIS MEANS WE DO NOT ACCEPT THAT INSURANCE.

MEMBER ID (REQUIRED TO VERIFY INSURANCE)*

YOU MUST SUBMIT MEMBER ID IF YOU HAVE INSURANCE, DO NOT LEAVE THIS BLANK. IF YOU ARE PAYING OUT OF POCKET PUT "N/A".

BRIEF REASON FOR SEEKING THERAPY *

QUESTIONS/CONCERNS

Please let us know of any questions you may have before beginning services.

This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you! Please give us 24 -48 hrs. to schedule your first appointment. We look forward to speaking with you!

Client Review:

This place is absolutely amazing. There are not enough words or time to describe how great Daysha and her staff are. She truly saved my family from past trauma. If you are looking for a comfortable place to start your healing please give this place a try.