Inquiry Form for Therapy Consultation

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Thank you for inquiring about therapy with Fostering Growth Therapy. Prior to scheduling your 15 min consultation, please fill out this form. Once this form is completed, you will receive an email with information about next steps for moving forward. If you have questions or problems with filling out this form, please email n.therapy@proton.me

Email *

First and Last Name(s) *

Phone Number *

Today's date *

YYYY

How soon would you like to schedule your first appointment? *

Are you requesting the completion of a form? Examples include, but not limited to disability claims forms or ESA letters/ *

Yes

What type of insurance do you have, HMO or PPO? *

Which specific insurance do you have? (Capital Blue Cross, Blue Cross/Blue Shield, Aetna, United HealthCare/Optum, UMR) *

If I do not accept your insurance, you will have the option of paying out of pocket and submitting a superbill to your insurance company for reimbursement? Is paying out of pocket an option for you? *

Yes

What area(s) in your life do you feel you need to focus at this time? What are your presenting issues/concerns? *

Where did you find out about Fostering Growth Therapy? *

Submit

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