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Existing Patient Online Portal

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DallasCTC.com Contact Form

Name of Person Completing Paperwork(Required)

First Last

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Name of Person Receiving Services

If different from person completing paperwork (e.g. minors, relationship counseling, etc).

First Last

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Pronouns

She/Hers

He/Him

They/Them

Ze/Hir

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Sex Assigned at Birth

Please note this information is required by insurance specific to the person seeking services.

Male

Female

Intersex

Other/Prefer Not to Say

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Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Date of Birth

Month

Day

Year

Phone(Required)

Email(Required)

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Age

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Insurance Provider

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Are you the primary subscriber for your insurance?

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Do you have secondary insurance?

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Help us book you even faster! If using insurance, please upload the front and back of your insurance card:

Max. file size: 300 MB.

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Help us book you even faster! If using insurance, please upload the front and back of your insurance card:

Max. file size: 300 MB.

How can we help?(Required)

Individual Therapy (Adult)

Individual Therapy (Kid/Teen)

Psychiatry & Medication

Group Therapy

Couples or Family Counseling

GAMHA

Something Else

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What is the *most important* thing you'd like to get help with?

We'll follow up to get more details, of course!

Where are you hoping to book an appointment?(Required)

Online (Telehealth)

In- Person

First Available

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Are any of these currently present (for you or the person seeking services)?

None of the Above

Serious thoughts of self-harm or suicide

Abuse or domestic violence

Lack of safety at home or work

Aggressive or violent tendencies

Shared custody or legal guardianship

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Insurance Card Upload

Please upload a copy of your current insurance card here.

Max. file size: 300 MB.

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How did you find out about us?(Required)

Google Search

Social Media

Word of Mouth

Community Event

Other

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Would you like to opt in to our mailing list (using the address you included above) to receive updates about the practice, new special programs and offers, and free tips and resources?

Yes

No

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Comments

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