Psychotherapy Interest Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred method of contact *

Email

Phone call

Text

I am interested in *

In-person appointments

Telehealth appointments

Both

What will be your method of payment? *

Insurance

Self-pay (we offer a pay-what-you-can tiered pricing model of $150 (supportive), $125 (standard), and $105 (reduced)

I don't know

If you are planning to use your insurance, please note that each practitioner accepts different insurance plans including Aetna PPO, BlueCross Blue Shield PPO/Choice, Cigna PPO, and United PPO plans. Which plan do you have?

Aetna PPO

BlueCross BlueShield PPO/Choice

Cigna PPO

United PPO

Other