Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone *

(###)

###

####

Type of therapy you're seeking *

Note: You can select multiple options.

Individual Therapy

Couples Therapy

EMDR Therapy

IFS Therapy

Coherence Therapy

Appointment Time Availability

Please let us know the time(s) of day that your prefer for your therapy appointments. Appointment time will not be scheduled until after the consultation meeting.

Weekday Mornings (8a-11a)

Weekday Afternoons (12p-3p)

Weekday Evenings (4p-6p)

Anytime (8a-6p)

Payment/Insurance Type *

If you plan to use insurance to cover the costs of therapy, which insurance do you plan to use? If you plan to pay without insurance, please select private pay.

Blue Cross Blue Shield

Blue Care Network

Priority Health

Aetna

I have an insurance that isn't listed here

Private Pay