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Please complete the form below to get started. If you have insurance, please enter your details so we can begin verifying coverage as soon as possible.

How did you hear about us? *

What is your first name? *

What is your last name? *

What is the best phone number to reach you at? *

What is your preferred email address? *

I'm interested in the program(s): *

Individual/Family Counseling (IN)

Outpatient Treatment (OP)

Outpost ( VA, Military, First Responders, Non-Civilian)

Mental Health Intensive Outpatient Program (MHIOP)

Substance Abuse Intensive Outpatient Program (SAIOP)

DayTreatment (DT/PHP)

Intervention

EMDR

Other:

Required

Insurance or self pay? *

Insurance

Self pay

Other:

If using insurance please list your date of birth, member ID and carrier name so we can verify your benefits.

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