Screening Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Preferred method of contact:
Please Select
Please Select
Text
Phone call/voicemail
Email
5
Select option
First Responder
Military/Veteran
Family Member of FR/Military
Athlete
Other
6
What has prompted you to seek therapy?* This field is required.
7
If you have health insurance, please select your insurance plan below:
Please Select
Please Select
Aetna
Ambetter
Community Health Plan (CHPW)
Coordinated Care
First Choice
Kaiser
Premera
Regence BCBS
Tricare
Triwest (VACCN)
Wellpoint
OON
Cash-pay
8
If your plan is not listed, I may not be contracted with them. Please list your carriers name below and I can check into it further (if out of network, a superbill can be provided to submit to your insurance carrier for possible reimbursement). If you prefer not not use your insurance and pay-out-of- pocket for services, please indicate 'self-pay' below.* This field is required.
Should be Empty: