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Appointment Request
To schedule a non-emergency appointment or obtain additional information about any of our counseling services, please complete the form below. Completion of this form does not guarantee an appointment.

You will receive an email response to your request within 72 business hours, so please check your inbox.  Our emails may be sent to your junk/spam folder, so please check there before submitting a follow-up request.

If you have an emergency or if you are in crisis, please contact 911 immediately or go to your nearest hospital's emergency department.


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Client name *
If you feel comfortable, please share your pronouns (i.e., They/Them, She/Her, He/Him, etc.)
Client Date of Birth *
MM
/
DD
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YYYY
Client Email Address *
Client Phone Number *
Can we leave a voicemail at this number? *
Type of Appointment *
Required
What days work best for you? (check all that apply) *
Required
What times work best for you? (check all that apply) *
Required
What office locations work best for you? (check all that apply) *
Required
I would like my therapist to have clinical interest or expertise in the following areas (check all that apply): *
Required
Your identities (race, religion, sexuality, gender) are important to us. Regardless if you are looking for specific support around these parts of yourself, we would like to know more about identities that are important to you, within yourself and within the clinician that you choose to work with.  If you feel comfortable, please share more about your identities below.
Insurance Information
While we do accept most insurances, there are several insurances that unfortunately, we do not accept at this time.  

We do not accept:
Medicare
Medicaid
Keystone First
Humana
Tricare
Compsych EAP (however, we do accept non-EAP Compsych insurance)

Please select your insurance provider from the list below or write in your insurance provider using the "other" field.  If you are offered and accept an appointment, you will be asked to register as a new client in our online practice management system.  Once this registration is complete, we will verify your insurance and will send your expected co-pay in the confirmation email that goes out before your first session.  

If you have any questions about your coverage, we encourage you to call the number on the back of your insurance card and inquire about your benefits for outpatient mental health office visits.
Insurance Company *
Please write your Member ID as it appears on your insurance card (include alpha prefix, if applicable). Or, if you selected EAP from the list above, please provide your authorization number. Write N/A if you do not plan to use insurance. *
What state do you currently live in? *
How did you hear about us?
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Additional preferences/comments/questions you would like to add to your appointment request.
If you are filling this out on behalf of the client: Please share your name, email address, phone number, and relationship to the client.
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