New Client Request Form

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If you'd like to get started with us, please fill out the form below and we will reach out to you!

Name of Individual Seeking Services (legal & preferred): *

DOB of Individual Seeking Services: *

What phone number can we reach you at? *

What email can we reach you at? *

Names, emails & phone numbers for parents/guardians IF applicable:

Preferred Appointment Days/Times: *

Primary insurance member ID if applicable:

Secondary insurance member ID if applicable:

Would you prefer in person or virtual therapy? *

In person

Virtual

No preference

What insurance carrier(s) do you have? *

Medicaid

Cigna

Aetna

United Healthcare

UMR

Kaiser/Carelon

Anthem BCBS

Traditional Medicare

Medicare Advantage Plan

Other

Self-Pay or No Insurance

Required

What are you seeking therapy for? *

Submit

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