Getting Started
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date Of Birth
*
-
Month
-
Day
Year
Date
We will only accept Blue Cross Insurance after 6/16/23.
Please visit the payment page on our website for our rates. Most plans will offer out of network 60-80% reimbursement. Call your insurance company to find out what your plan covers.
Insurance Name
*
Insurance Group Number
*
Please Upload Images Of Your Insurance Card (Front and Back)
*
Browse Files
Cancel
of
Primary Insured's Name
*
First Name
Last Name
Primary Insured Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Therapist
*
Michele Waldron
Susan Ott
Terry Burch
No Preference
What Service Or Services Are You Looking For?
*
Individual Therapy
Couples Therapy
Intensive Couples Therapy
Men's Compulsive Behavior Groups
Betrayal Trauma Partner Group
Pelvic Pain Group
ADHD Men's Group
Partner of ADHD Individual Group
How can we help you? Please be specific so we can match you with the best clinician
*
Preferred Time For Sessions
*
Please Verify That You Are Human
*
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