Your name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Is it ok to contact you via text? Yes No Is it ok to leave a voicemail? Yes No Insurance Blue Cross Blue Shield (BCBS) UHC Commercial/UHC Community Aetna Ambetter Healthy Blue Self pay What is your primary reason for seeking therapy? Anxiety Depression Self Esteem Relationship Concerns Other What prompted you to seek therapy? * Give a description of what led you to seek therapy. This can be brief--We'll get into the details later. Thank you! I’ll be in touch with you over the next couple of business days to schedule a consultation. Remember, if this is an emergency or you feel unsafe, please contact 911.
