Request for Intake Session
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Email *
Legal Name (Please specify if you have a separate chosen name) *
Phone number (with area code, please) *
Date of Birth *
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Reason for seeking counseling *
Are you wanting individual, couples, or family counseling? *
Availability for regular ongoing sessions (times/days of the week) *
Our office is in a multi story building with an ADA accessible ground floor. Do you prefer to meet in a ground floor office instead of one on the second floor? *
Will you being paying privately or using insurance? *
If using insurance, please specify your insurance carrier. (ex: Anthem, Aetna, United Healthcare, etc.) *
Is your insurance a Medicaid plan? *
Do you have Medicare insurance? *
Do you have more than one insurance policy that pays for behavioral/mental health services? (Also known as secondary insurance?) *
Do you prefer telehealth or in person sessions? *
Do you have a preference of provider? *
How did you find us? (Please tell us the name of the person who referred you if you were referred by a friend or another provider.)
A copy of your responses will be emailed to the address you provided.
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