Ancestral Realms

Therapy Intake Form 

Have you had therapy in the past? *
In the past, have you experienced any of the following:*
What is your recent level of Self Love?*
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Welcome to my practice!

As you are initiating contact, I would like to familiarize you with the process of here at Ancestral Realms.


Appointments are set on an individual basis: Monday through Friday 10 am - 5 pm.  

Meetings and Communications are in-person office visits or online via zoom. Setting appointments occurs via email, phone or in person. Please keep email and phone messages concise and business oriented.  We apologize there is no text-ability. All personal information is to be shared during our in-person-times together.


Payments are made by check, cash or via PayPal (additional fees may apply). Therapy sessions are priced at $180/hr.


Insurance - Services provided are considered an 'out-of-network' reimbursement. Depending on your health benefits, services may be covered in full or part by your health insurance or employee benefit plan. Please check your coverage carefully by asking the following questions:

  • Do I have mental health insurance benefits?
  • What is my deductible and has it been met?
  • How many sessions per year does my health insurance cover?
  • What is the coverage amount per therapy session?
  • Is approval required from my primary care physician?


Cancellation Process:

For one on one appointments we have a reservation with you and give up other appointment opportunities to accept yours. As time and space is set for you, we practice with a 3 business day cancellation or reschedule policy. If you are unable to keep your scheduled appointment, kindly provide notice by calling: 610-513-2757. Business days are Monday through Friday.

Cancellation rates: Rescheduling rates are $75. Missed appointments or late cancellations are full fee: $180-290. True emergencies are most certainly honored and free of charge.


Thank you for taking the time to prepare me to work with you competently. I look forward to meeting and exploring with you how to be of service to you! 

Once your intake is received, the next step is to set appointment times. I will contact you as soon as I receive all of your information - no more than 3 business days past reception.



Andrea Bosbach Largent, msw, sft