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Consultation Request
Please complete this secure form and after submission you will be redirected to book your free consultation call through our internal system.
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Last Name
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Your answer
First Name
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Your answer
Email Address
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Your answer
Phone Number
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Your answer
Age
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Your answer
Where are you located?
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New York
New Jersey
Connecticut
Massachusetts
Texas
North Carolina
Florida
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Which therapist are you looking to have a consultation with?
If you are not sure who you would like to book with, please book your call with Mary Tate to help match you with the best fit.
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Mary Tate, LCSW (on vacation until June 7th 2023)
Muriel Radocchio, LCSW
Radyale Soman (Blaylock), LCSW
Elizabeth Tullis (Bittiker), MFT
Please share any details that may be helpful for the therapist to know prior to your call. (
what you hope to work on, current symptoms, questions you may have)
Your answer
Payment Preference
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Out of Pocket
Out of Network (we will help walk you through the claim process!)
*Raydale Only* In Network with United Healthcare, Oxford, Oscar, Optum
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Will you or a 3rd party be responsible for financial responsibility?
This gives us a heads up on how to review any financial questions that you may have during your call!
I will be responsible for all financial responsiblity.
A 3rd party will be responsible for financial responsibility. (Parent, Spouse, Family Member, Friend, Employer)
How did you find us?
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Alma
My Wellbeing
Word of Mouth
Corporate Wellness Webinar
Instagram
TikTok
Provider Referral
Therapy Den
You Are Accountable
Psychology Today
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Do you have a preference of how we communicate with you prior to your consultation?
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