Wellness Care Interest Form 2026

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Please help us keep services accessible at Radical Healing by completing this survey for your intended healthcare use in 2026. Thank you in advance!

Full Name on Insurance Card *

Full Chosen Name *

Email *

Phone Number *

Current Use

1a. Which of the following services do you currently use at Radical Healing?
*

Therapy (mental health counseling)

Psychiatry (medication management)

Primary Care

Physical Therapy

Other:

Required

1b. Please select each provider you see.

Alicia Montes-DeGraff

Alexis Smith

Allison Clark

Amanda Woodham

Arlo Anastasi

Ashley McNatt

Ava Johnson

Britt Coker

Brittany Galego Fischer

David Young Oh

Destry Taylor

Donyelle Miller

Emil “Em” Eichelberger

Finn Losch

Givie Lanier

Haley Cohen

Haley Pittman

Hayley Cunningham

Hillary MacKenzie

Iman Abdulkadir Said

Jemm Merritt

Jessica Klein

Jay Schnaak

Joshua Baum

Katherine Downs

Kyley Underhill

Kristina Gayle Morris

Kristy Miller

Lala Bailey

Marcus Walton

Marquise Eloi

Marvice Marcus

Mazella Fuller

Matt Trower

McClaren Pine

Nicholas Little

Olufemi Shittu

Oona-Ifé Olaiya Wright

Patricia Blum

Rheaya Willis

Sam Matthews

Samara Domanski

Sara Graham

Sara Skinner

Sarah Schmidt

Shanti Bowling

Stephanie Martinez

Stephanie Perez Toro

Teresa Ray

Zakiya Futrell

2. How often do you currently use these services at Radical Healing?
*

Weekly

Bi-weekly

Monthly

Every 2-3 months

Every 6 months

Annually

Less (as needed)

Not at all

Therapy

Psychiatry

Primary Care

Physical Therapy

3a. What type of insurance coverage do you currently have?
*

Employer-sponsored plan

Marketplace / ACA plan

Medicaid

Medicare

Self-pay / uninsured

3b. If you have insurance, what is your carrier (i.e., United Healthcare, Amerihealth, etc.)?

Future Use

4a. Have you heard about or received notice of premium, deductible, or copay increases for 2026?
*

Yes, I’ve already been notified of increases

I expect increases but haven’t received official notice yet

No, I haven’t heard of any changes

Not sure

Required

4b. Will you be changing your insurance in 2026?
*

Yes

Not sure

4c. What insurance plan will you use for 2026?
*

Employer-sponsored plan

Marketplace / ACA plan

Medicaid

Medicare

Self-pay

I do not plan on enrolling in health insurance for 2026

4d. If you have insurance, what is your carrier (i.e., United Healthcare, Amerihealth, etc.)?

5. How concerned are you about being able to afford healthcare costs in 2026?

Not at all concerned

Extremely concerned

Clear selection

6. Do you expect your frequency of visits to change in 2026 due to insurance or cost changes?
*

Yes, I expect to use services less often

Yes, I expect to use services more often

No, I expect about the same usage

Not sure

7. If you expect a change, please explain why.

8. How often do you anticipate using these services in 2026 at Radical Healing?
*

Weekly

Bi-weekly

Monthly

Every 2-3 months

Every 6 months

Annually

Less (as needed)

Not at all

Therapy

Psychiatry

Primary Care

Physical Therapy

9. Which Radical Healing services do you expect to continue using most regularly in 2026?

Therapy

Psychiatry

Primary Care

Physical Therapy

None / undecided

Subscription & Direct Pay Options

10. If insurance costs increase significantly, how interested would you be in a flat monthly or annual “subscription” plan (e.g., one fee covering certain visits or messaging access)?
*

Not interested

Very interested

11. Which subscription model sounds most appealing to you?
*

Monthly fee covering 5+ monthly visits

Monthly fee for a set number of visits (e.g., 2–4 per month)

Annual membership with discounted visit rates

Pay-per-visit only (no subscription)

Other:

Required

12. What price range would you consider reasonable for a subscription plan that fits your needs?
*

Under $50 per month

$50–$99 per month

$100–$199 per month

$200–$299 per month

$300–$399 per month

$400–$499 per month

Not sure / depends on what’s included

13. Which services would you want included in a subscription or membership plan?
*

Individual therapy sessions

Group therapy sessions

Psychiatry visits/medication management

Gender affirming care (e.g., hormone replacement therapy, letters for gender affirming surgeries, therapeutic support)

Menopause/perimenopause support

Weight autonomy (e.g., nutrition services, disordered eating, GLP-1, etc.)

Sexual and reproductive health (e.g., STI screening, PrEP, DoxyPEP, IUDs, pregnancy test, etc.)

Primary care visits

Movement classes (e.g., pilates, yoga)

Physical therapy sessions

Patient navigator sessions (e.g., federal resource application support, referrals, care coordination)

Other:

Required

Additional Feedback

14. What could make healthcare more affordable and accessible for you in 2026?

15. Would you like to be contacted if Radical Healing explores new membership or subscription options?
*

Yes

Thank you for sharing your input! Your responses will help Radical Healing plan for changes in the 2026 healthcare landscape.

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