Therapy Consultation Preference Form

However you prefer to start, we'll meet you there. Complete the form below and you'll be redirected to our calendar to choose a time for your 30-minute consultation.

➡️ Prefer to skip the phone call? 📲 Click here to fill out our self-service consultation questionnaire, and we'll reach out via email within 24 hours to book your intake appointment.

First name

Last name

Email

Phone

If you go by a name that's different from your legal name, please share it here so we can address you correctly.

Self-pay? You can skip the remaining questions and scroll down to the submit button to complete your form. Our out-of-pocket rate is $135 per session.

If you'll be using insurance to pay for sessions, please select the name of your carrier.

If the insurance company you have a plan with is not listed, we'd be happy to see you as a self-pay client for $135 per session.

Birthday

Month

Day

Year

Your date of birth helps us verify your insurance benefits accurately. This information is kept confidential and used only for coverage verification.

If you plan to use insurance for your sessions, please upload a clear photo of the front of your insurance card. This helps us verify your benefits before your consultation so we can confirm your co-pay and coverage details.

Please be sure to upload both sides of your insurance card so we can verify your insurance details in advance.

Please upload a clear photo of the back of your insurance card. This side often includes important contact and plan details that help us during the verification process.

Please be sure to upload both sides of your insurance card so we can verify your insurance details in advance.