Book An Appointment

Appointment Request Form

Please complete the intake form bellow and a coordinator will reach out to you by the next business day to help you get started.

First name*

Last name*

-Only applicable if client is a minor- Name of Parent/Guardian

Email*

Phone*

Can we leave a message?*

Yes

Address*

Birthday*

Month

Day

Year

How did you hear about us?*

Brief reason for seeking counseling*

Type of Counseling

Prefer a specific counselor? Let us know!

Do you plan to use insurance? We currently acceptAetna, UnitedHealthcare, Cigna and Optum Care Network.

Yes

Not Sure

If yes, which insurance company?

Insurance Member ID

Which days of the week do you prefer? (select all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Time of day you prefer? (select all that apply)

Morning

Afternoon

Evenings

Preference for male or female therapist?

Male

Female

Either

Preference for In-Person or Telehealth?

In-Person

Telehealth

No preference

If you would like to be seen sooner, we can offer services from our practicum trainees or master's level associates under the supervision of a licensed therapist. Are you okay to be seen by an associate or trainee?

Yes

I want to learn more

Thank you for taking the time to fill out this form. We appreciate you reaching out to us. We look forward to supporting you.

Before we can make an appointment for you, we will need to speak with you to review your Intake Form responses and obtain additional information. Please provide your availability over the next 3-5 days for a 15-minute call.

Long answer*

List 2-3 days and times we can reach out to you for a 15-minute phone call.