New Client inquiry formPlease fill out the following form if interested in services from Harmonie Within Which service are you interested in? * Therapy Life Coaching Yoga Mindfulness Meditation Group Retreat or Workshops Name * First Name Last Name Parent or Guardian Name If under 18 years old First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance * Aetna Anthem BCBS Cigna Harvard Pilgrim Health New England Husky/Medicaid Medicare Optum/United/Conneticare Oxford No Insurance/ Self Pay/ Other Provider Services or Benefits Phone Number * if no insurance then put N/A Insurance ID Number * If no insurance put N/A Anything else you might want us to know Thank you for submitting this form!
