Request an Appointment Privacy Policy "*" indicates required fields Your Name* Name of caregiver or contact person, if different from patientYour Relation to Participant*SelfParent/CaregiverOtherName of Participant* Participant Date of Birth* Email Address* Email address to send scheduling and other informationPhone Number* Phone number to call regarding scheduling and other informationPreferred Contact Method(s) Call Text Email Select AllAre you interested in utilizing health insurance benefits for our services?* Yes No Unsure, I would like more information Please note that eligibility depends on your health insurance company and your individual plan. We do not guarantee that the service you request will be billable to your insurance.Primary Insurance Provider* Name of Insurance CompanyPrimary Member ID Member and/or Group Number on PolicySecondary Insurance Provider Name of Secondary Insurance CompanySecondary Member ID Member and/or Group Number on PolicyDesired Therapy Program(s)Which program(s) would you like us to contact you about? Not Sure- Help Me Choose! Art Therapy Music Therapy Recreational Therapy Talk Therapy Group Therapy Life Skills Classes My Little Love & Me Classes Select AllDo you have any questions or other information you would like to share?Please check this box if you would like to be added to our mailing list to receive updates from Sunny Days Therapeutics. Yes, please add me to the mailing list! Please check this box to acknowledge that we may contact you through our secure Therapy Notes portal for scheduling and other administrative purposes.* I agree to be contacted through the Therapy Notes portal CommentsThis field is for validation purposes and should be left unchanged.
