Appointment Request Form

Request an Appointment

Fill out the below questionnaire to see if we have a therapist available who can meet your needs. We are currently offering clients their choice of in-person or telehealth sessions or a combination of both.
DateTime
Who are you seeking an appointment for? (Mark all that apply) *

Myself My Spouse/Significant Other My child(ren)
Mark the type of therapy you are looking for. (Mark all that apply) *

Individual Counseling Couples/Marriage Counseling Family Counseling Group Counseling
What kind of group would you be interested in attending?
List all individuals you are seeking therapy for *

Contact Information

If we have a therapist available that meets your needs, we will email you some paperwork so we can finish setting up an appointment. Each individual attending therapy will need their own set of paperwork completed.
Name *

First Name Last Name
Email *
example@example.com
Phone Number

Area Code Phone Number
Person filling out this form's Name *

First Name Last Name
Person filling out this form's Email *
example@example.com
Person filling out this form's Phone Number

Area Code Phone Number
Spouse/Significant Other’s Name *

First Name Last Name
Spouse’s/Significant Other’s Email
example@example.com
Spouse/Significant Other's Phone Number

Area Code Phone Number
Each family chart is set up under one client name. For family sessions, which family member would you like the chart to be set up under.

First Name Last Name
Add any additional information you feel is important for us to know before setting up an appointment (optional)
Payment Type

I would like to see if I can use my insurance. The office staff can get me a quote of benefits from my insurance company to give me an anticipated session cost. All final payments due will be based on actual insurance payments received. I would like to see a licensed therapist at the self-pay rate of $130 per session.
Select your insurance from the drop down list below: *
Most of our therapists are in-network with most plans that use one of the above insurance networks. If you do not see your plan select "other insurance not listed" and write your plan below. We cannot accept most Medicaid plans nor most EAPs.
What insurance were you hoping to use?
Should be Empty:

Request an Appointment

Help Us Find the Right Therapist for You

Schedule

Contact Information