New Client Form — Alexa Baz LCSW

I am an out-of-network provider eligible for reimbursement by many PPO insurance plans. Unfortunately, I am NOT eligible for reimbursement by Medicaid or GHI.

Your Name

First Name

Last Name

Your Date of Birth

YYYY

Phone

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reason for Contacting

Available times for appointment

Preferred Method of Contact