Schedule An Appointment

Schedule An Appointment

Enter your details to receive a call back from us.
Full Name*

First NameLast Name
Date of Birth*
Ex: mm/dd/yyyy
Phone Number*
Please enter a valid phone number.
Administrative Sex*
Gender Identity*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Provider [if you plan to pay direct rate, please put none]*
Insurance ID and Group Number [if you plan to pay direct rate, please put none]*
Are you the primary subscriber?*
If not, who is?
Include Name, DOB and Relationship to Patient
Service Preference*
I understand that if I choose to use self-pay rather than insurance, the rate is $175 for the initial intake appointment and $125–$150 for each subsequent session. Alternatively, I may opt to work with an intern at a rate of $50 per session or apply for the sliding fee scale to determine if I qualify for reduced-rate sessions with a clinician at the practice.*

N/A - I plan to use insuranceI agree to the full rate of $125-$175 a sessionI would like to see an intern at the $50.00 rateI would like to apply for the sliding fee scale
Marital Status*

UnmarriedMarriedDomestic PartnerDivorcedWidowLegally SeparatedInterlocutory DecreeAnnulledSomething ElseChoose Not To Disclose
Employment Status*

Full-Time EmployedPart-Time EmployedSelf-employedContract, per diemFull-time StudentPart-time StudentOn active military dutyRetiredLeave of absenceTemporarily unemployedUnemployedSomething else
Group Therapy Preference (If Applicable)?
Which location would you prefer?*
What is your time preference? (Select all that apply)*

Morning 8:00 AM - 12:00 PMAfternoon 12:00 PM - 5:00 PMEvening 5:00 PM - 8:00 PMFully Open Availability
What days of the week do you prefer? (Select all that apply)*

MondayTuesdayWednesdayThursdayFridaySaturday
I understand that by completing this form, if an agreed-upon date and time are reserved for me, I am subject to the practice’s cancellation policy. Should I fail to attend my scheduled appointment or cancel with less than 24 hours’ notice, I will be responsible for a $75 missed appointment fee or a $50 late-cancellation fee, which will be invoiced accordingly.*
Type a question*

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