Respark Client Inquiry Form
Welcome to Respark, We're so glad you're here. Please fill out the information below to take the first steps toward working together. Next, we'll contact you to schedule your first appointment.
Full Name *
Your answer
E-Mail Address *
Your answer
Best Contact Phone Number *
Your answer
May we leave a message at this number? *
How would you like to be contacted? *
How did you hear about us?
Some of our clinicians offer sessions online. Please indicate here if you would like to request this option.
What type of therapy are you looking for? *
Tell us about your ability to pay
Our services start at $125 per session for individual and $150 for couples for most clinicians. We have several lower fee spots available to those in need starting at $45/session.

Respark is currently offering service to those using their out of network benefits which means you can submit a receipt (called a superbill) to the insurance company receive reimbursement for out of pocket payments directly from them. You can call your insurance company to see if your plan has out of network beinfits. Please check with your provider to verify your benefits. We also accept health savings accounts and flexible savings accounts depending on your provider.

What city do you reside in? *
My ability to pay is: *
Please briefly describe what you would like to accomplish in therapy *
Your answer
Did you find a particular therapist on our website that you would prefer to work with? Please note with online sessions, you must have address of the state listed next to the Therapist. *
Anything else you'd like us to know?
Your answer
Thank You!
We appreciate your taking time to fill out this information. You should expect someone from Respark to contact you within the next two business days.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.