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Home
Specializations
Services
Our Team
FAQ
Blog
Request A Session
Contact
Request A Session
Legal Name
*
First Name
Last Name
Preferred Name/Nickname
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
Online Search
Therapist Database (Psychology Today, Mental Health Match, Monarch, etc)
Insurance Company Database
Social Media
Return Client
Other
Insurance Carrier
*
Aetna
Allied Benefit Systems
BCBS PPO
Blue Choice PPO
Cigna/Evernorth
United/Optum
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
*
DOB is needed to verify health insurance benefits
MM
DD
YYYY
Zip Code
Please indicate the zip code that is attached to your health insurance plan.
Type of Appointment
Individual Therapy
Couples Therapy
Sport Psychology Consulting
Corporate Wellness
EMDR
Reiki
Preferred Appointment Day and Time
*
Check all that apply.
Weekdays 8am-11am
Weekdays 11am-2pm
Weekdays 2pm-5pm
Weekdays 5pm-9pm
Saturdays 8am-1pm
Sundays 2pm-7pm
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.
Anxiety
ADHD
Autism
Body Image
Chronic Pain + Illness
Depression
Grief
Identity Development
Life Transitions
Mood Disorder
OCD
Sport Performance
Stress Management
Self-Esteem
Suicide + Self-Harm
Trauma + PTSD
Eating Disorder
Women's Issues
Cultural Concerns
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! We will get back to you within 2 business days to set up an appointment!
