Get the Help You Need to Thrive

Name *

First Name

Last Name

Phone

(###)

###

####

Do you understand sessions are virtual only? *

Online sessions via Google Meet secured platform

Yes, I understand

Do you understand we accept cash pay clients & a select number insurances? *

The insurances we accept are: Aetna, United Healthcare, UMR, & Lyra. A superbill can be provided for cash pay clients.

Yes, I understand

*Disclaimer* *

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.