Request an Appointment
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Patient Name *
First and Last
Patient Date of Birth *
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Email Address *
Phone Number *
Gender *
Please provide a brief summary of reason for seeking counseling.
 *
Insurance Information

Please verify your benefits with your individual plan as coverage varies and some major insurances subcontract mental/behavioral health to a different insurance provider. 

Who is your Primary Insurance Provider?
 *
Do you have secondary insurance? If so, who is your secondary insurance provider? *
Please Select which clinician you would like to be scheduled with.
 *
We offer both virtual and in-person sessions, what are you open to? *
When are you available? *select all that apply *
Required
If you are submitting a request for someone other than yourself please provide your name and relationship to the patient.
If this is a request for a child, is there any type of shared legal custody? (If there is shared legal custody we will need to obtain consent for services from all parties) 
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How did you hear about us? *
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