Schedule An Appointment
Enter your details to receive a call back from us.
Full Name
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First Name
Last Name
Date of Birth
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Ex: mm/dd/yyyy
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
Insurance Provider [if you plan to pay direct rate, please put none]
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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.
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N/A - I plan to use insurance
I agree to the full rate of $125-$175 a session
I would like to see an intern at the $50.00 rate
I would like to apply for the sliding fee scale
Please provide a general idea of what you are seeking support for. This is not required, but it helps us match you with the clinician whose specialties and areas of expertise best align with your needs.You are also welcome to share any additional preferences you may have when being matched with a counselor. While we may not always be able to accommodate every preference, we will do our best to find the right fit for you.
I understand that if my address is located in Kentucky, I may only receive in-person services at an office located in Tennessee. For virtual appointments, I understand that I must be physically located in Tennessee at the time of the appointment unless I am assigned to a clinician who is specifically licensed to provide services in Kentucky.
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I understand - I have a KY address and will need to discuss options
I understand - I have a TN address
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.
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Please Select
I agree
Signature
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