Appointment Request Form
Fill out this form to request an appointment for yourself. We look forward to meeting you!
First Name*
Last Name*
Enter Your Date of Birth in this format: YYYY-MM-DD*
Age*
Email*
Phone*
How did you hear about us?*
Google Search
Word of Mouth
Facebook Ad
Referral
Please select your primary reason for seeking therapy:*
Depression
Anxiety
Relationship Issues
Substance Abuse
Family Conflict
LGBTQIA Topics
Grief Loss
Life Transition
Perinatal Support
Stress Management
Communication Skills
ADHD
Autism Spectrum Disorder
Behavioral
Adjustment/Transition Difficulty
Other
Which type of therapy are you seeking? NOTE: for those who select Couples Counseling, please have your parnter complete a second form*
Individual Therapy
Couples Counseling
Child Therapy
Other
Select additional reasons for seeking below (check all that apply):
Anxiety
Depression
Relationship Issues
Substance Abuse
Family Conflict
Grief/Loss
Life Transition
LGBTQIA
Perinatal Support
Other
Stress Management
Communication Skills
ADHD
Autism Spectrum Disorder
Behavioral
Adjustment/Transition Difficulty
Insurance Provider*
Anthem BC/BS
United Healthcare
Humana
Custom Designs
Tricare
Optum
My provider is out of Network
Primary Policy Holder Name
Primary Policy Holders Date of Birth
Insurance Member ID*
Primary Insurance Group Number
Insurance Coverage Start Date
Insurance Coverage End Date
If your insurance is covered through your work, please list your employer below
Street Address (This is used to verify insurance eligibility.*
City*
State*
Zip Code*
Are you open to telehealth?*
Yes
No
What is your preferred contact method?*
Phone
Email
Text
All of the Above
Preferred Appt Time*
Mornings
Afternoon
Evenings
Preferred Appointment Days*
Monday
Tuesday
Wednesday
Thursday
Friday
Can we follow up with a survey?*
yes
no
We will call you to learn more in order to match you with the best therapist. Is there anything else you'd like us to know?
Please verify your request*
Submit