Request Consultation
Our intake coordinator will get in touch with you for a 15-minute consult within 1-2 business days.
Client name
*
First Name
Last Name
Are you a minor?
Yes
No
Name of parent or guardian (if client is a minor)
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
How did you hear about us?
Please Select
Google Search
Psychology Today
Referred by Medical Professional
Facebook
Instagram
Current or former client
Friend
Family member
Other
Who is filling out this form?
Client (I am the client age 18 or older)
Parent or legal guardian (client is a minor)
Referral (I am filling this out for someone else)
Other
Are you court mandated for therapeutic services?
Yes
No
What time of day is best to call you?
Morning (9:00am - 12:00pm)
Afternoon (12:00pm - 4:00pm)
Evening (4:00pm - 6:00pm)
Other
Mental Health Therapist Preference
Tanya Bingham, LCSW (accepts most major insurances) TELEHEALTH
Alicia Price, LCSW (accepts Husky/Medicaid and Anthem BCBS) In-person and Telehealth available
Karla Dunkley, LADC (accepts Husky/Medicaid and United/Optum/Connecticare)
Taminesha Holley (CLINICAL INTERN -- Sliding scale only)
Which do you prefer?
In-person (limited availability)
Telehealth/virtual
Will you be using insurance? (please check your insurance benefits as these may vary for mental health services.)
Yes
No
Primary insurance
Please Select
Anthem Blue Cross/Blue Shield
Cigna
Husky/Medicaid
Unitedhealth Care/Optum
Connecticare
Out-of-network benefits
Self-pay/out of pocket
Other/not listed
Secondary insurance (if applicable)
Please Select
Anthem
Blue Cross/Blue Shield
Cigna
Husky/Medicaid
Unitedhealth Care
Optum
Connecticare
Other/not listed
What kind of therapy have you engaged in previously?
Not applicable/first time in therapy
Eye Movement Desensitization and Reprocessing (EMDR)
Cognitive Behavioral Therapy (CBT)
Inpatient Psychiatric Treatment
Intensive Outpatient Program (IOP)
Substance Recovery
Couples Therapy
Family Therapy
Other
How soon would you like to schedule your first session?
Earliest Available
Within the next 1-2 weeks
Within the month
Next month or later
What is the main concern you would like to address in therapy?
Anything else we should know?
CONTACT US
Should be Empty: