Patient's Legal First Name (Not Parent's) - As shown in ID / Insurance Card
Patient's Legal Last Name (Not Parent's) - As shown in ID / Insurance Card
We will contact you via email with some options to help you get started.
An Email is required to create a client portal account. This form is HIPAA secure, but your email, phone, or messages may not be.
Please attach a copy of your insurance card to this form (Both Sides)
Payment Options (Out-of-Pocket)
Not accepted: BCBS (Couples or Family), EAP, Magellan, Medicare or Medicaid plans
Please include full ID (3 letter prefix for BCBS Insurance)
Please make sure to read visit your preferred therapist profile before selecting an option. Some of our therapists may not be accepting new clients (waitlist only) or may not accept your preferred payment option (insurance)
Suggested Frequency: Please keep in mind we highly suggest a minimum of 6-8 weekly sessions when starting therapy, along with a regular weekly commitment. This will contribute to building a trustful relationship with your therapist and prioritizing your process of healing and growth.
Please share with us what is most important to you when choosing a therapist so that we can share with you the best options to help you get started
Is there anything else we should know before our team reaches out to you?
If not please submit "NA". A member of our support staff will respond in the next 2 business days.