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Services inquiry
Who is seeking services?
First Name
Last Name
What is the best phone number to contact you?
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Please enter a valid phone number.
Can this number receive text?
Yes
No
Valid Email
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example@example.com
Interested in:
Individual Counseling (adolescent 10-23)
Individual Counseling (adult 24+)
Couples/Marriage counseling
Consulting
Substance Abuse
Brain Spotting Only
Team Building/Mental Check in
What state do you currently reside?
Tennessee
Kentucky
Texas
Ohio
How do you plan to pay for services
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Private Pay
BCBS
BCBS (Optum Behavioral Health)
United Health
Optum
Aetna
Cigna
TriCare East
Medicare (Please check if a referral if needed).
Other (Please state type of Insurance)
Reasons for seeking out services?
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