Let's get you started with Mountain View Therapy!

If you're interested in our services, please complete the form below, and we’ll get back to you as soon as possible. If you’re filling out this form on behalf of someone else, please provide the details of the person who will be receiving care.

To learn more about Mountain View Therapy and our approach, visit our website.

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Email *
First Name (you go by-- we'll ask for the name the insurance company has later) *
Last Name *
Please enter your phone number:
What's getting you to reach out to us today? *
Who is the primary client? *
Contact

Please provide the name of the contact if the client is a minor
How do you plan to pay for our service?

***If you prefer not to use your health insurance, we offer a sliding scale for individuals experiencing financial hardship to ensure access to care regardless of their financial situation.
 *

If you plan to use insurance, providing your insurance information allows us to quickly confirm coverage and match you with a clinician as soon as possible.

You can also email a picture of your insurance card at referral@mountainviewtherapyma.com

What is your primary health insurance company?
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Insurance ID Number:
Name on File with Insurance Company and Subscriber's Name:
Subscriber Date of Birth:
Do you have secondary insurance? If so, what is the health insurance company?
Please let us know about your preferences so we can match you with a clinician. 
You can learn more about our exceptional team of clinicians and our approach to providing therapy by visiting our website.
Do you have a preference for one of our clinicians?
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Do you have preferences around days of the week or times of the day? 

We’ll do our best to accommodate, though availability may vary. 
How often do you hope to meet?
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How did you hear about us? *

Thank you for taking the time to provide us with this information. We’ll be in touch with you soon!

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