Home
Specializations
Services
Our Team
FAQ
Blog
Request A Session
Contact
Home
Specializations
Services
Our Team
FAQ
Blog
Request A Session
Contact
Work with Ally
Name
*
First Name
Last Name
Pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Email
*
Phone
*
(###)
###
####
Preferred Contact Method
Email
Phone
No Preference
How did you hear about us?
Referral from Friend/Professional
Internet Search
Therapist Database (Psychology Today, Mental Health Match, etc)
Insurance Company Database
Social Media
Return Client
Other
Insurance Carrier
*
Aetna
Allied Benefit Systems
Cigna/Evernorth
BCBS PPO
Blue Choice PPO
Self-Pay
Member ID
*
Please write N/A if self-pay
Group Number
*
Please write N/A if self-pay
Customer Service or Provider Phone Number
This phone number can often be found on the back of your insurance card. Including this number will expedite verification of benefits. Please write N/A if unsure.
Date of Birth
*
Date of birth is needed to verity insurance benefits
MM
DD
YYYY
Zip code
Please indicate the zip code that is attached to your health insurance account.
Preferred Appointment Day and Time
*
Check all that apply.
Weekdays 8am-11am
Weekdays 11am-2pm
Weekdays 2pm-5pm
Preferred Appointment Location
*
Video
Office
No Preference
Reasons for Appointment
*
Please check all that apply. If you do not see your reason for attending therapy listed, or want to expand on any of the items listed, please do so below in the message box.
Alcohol Use
Anxiety
ADHD
Behavioral Issues
Bipolar Disorder
Couples Therapy
Depression
Grief
Identity Development
Life Transitions
Relationship Issues
Self-Esteem
Stress Management
Trauma + PTSD
Women's Issues
Other
Message
Please include any information about why you are seeking our services at this time. If you have more specific preferences for appointment days and times than what is listed above, please indicate that here.
Thank you! Our intake team will be in contact within 2 business days to get you scheduled with Ally!
