Appointment Request Form

Please complete the following form to request your appointment.

First Name *

Last Name *

Phone *

Email *

How did you find us? *

Whom Are You Seeking Counseling For

Would your like first availability or work with a specific clinician?

How would you like to receive services?

In-Person Only

Telehealth Only

Open to Both

Feel free to briefly describe the issue you would like to work on.

Insurance Information (Optional)

You do not have to provide this info here if you'd prefer us to call you to obtain it.

Who is your insurance carrier for mental/behavioral health?

Member ID

Date of birth (required to verify insurance)

Insurance Card Front/Back (Optional)

Insurance Card Front/Back

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