Request an Appointment
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First name of the individual receiving services
 *
Last name of the individual receiving services
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Email address *
Phone *
Format: (000) 000-0000
Date of birth of the individual receiving services *
MM
/
DD
/
YYYY
Sex (as listed on insurance policy)
 *
What is your current gender identity? (Check one)
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Street address 1 *
Street address 2
City *
County *
State of residence

We're currently only in AZ, CO, MA & VA
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Zip code *
What type of services are you looking for? *
Required
Which provider(s) are you interested in working with?

You can view our providers on this page.

Please list all the providers you're interested in working with in your state. We'll do our best to find the earliest available appointment for you.
 *
If the provider you selected is not accepting patients, can we match you with another provider? *
Are you on Medicaid or Medicare? 

Please select all options that apply. For instance, if you're enrolled with both Medicaid and Medicare, please select the checkboxes for both options.
 *
Required
Insurance provider *
Policy number
 *
Are you the primary subscriber of this insurance policy? *
When are you available for an appointment? In an effort to schedule you as efficiently as possible, please be sure to select any times that you are available for weekly appointments.

By submitting the form, you consent to Third Space using the times you provided below to schedule your appointment with a therapist
Monday
Tuesday
Wednesday
Thursday
Friday
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
Consent to SMS text messaging
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How did you hear about us?
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If you were referred to us, please enter the name of the referring provider and their practice name *
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