Getting Started

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Introspection & Reflection LLC

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

GETTING STARTED

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 *

SELECT BELOW

MEMBER ID (REQUIRED TO VERIFY INSURANCE)*

YOU MUST SUBMIT MEMBER ID IF YOU HAVE INSURANCE. 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.

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

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 not after insurance verification we will contact you if your plan includes a deductible to meet or co-payment for sessions. Medicaid insurance companies such as Amerigroup, Caresource, and Peachstate do not have deductible and co-payments to meet, sessions are covered at 100%.)

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.*

Get in touch!

Address

114 Canal Street

Suite 203

Pooler, Ga. 31322

Contact

Office: (912) 737-2176

Fax: (912) 330-1035

Hours

Mon-Fri: 9:00am - 5:30pm
Sat: Closed
Sun: Closed

GETTING STARTED

Get in touch!

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Hours

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