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Name
first name
last name
Phone
provide caregiver's phone for child / teen clients
e-mail
provide caregiver's email for child / teen clients
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Male
Female
non-binary
other
Appointment Type
Please Select
Individual Counseling (for myself)
Individual Counseling (for a 5 to 11 yr old under my care)
Individual Counseling (for a 12 to 17 yr old under my care)
Individual Counseling (for an adult other than myself)
Couples Counseling (for myself and my partner)
Family Counseling (for myself and my family members)
Preferred location
Please Select
Southlake office
Flower Mound office
Highland Park office
via Telehealth
Would you like to request a specific counselor?
Yes, let me select from your list
No, assign me to a the best matching / first available counselor.
Southlake counselors
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Gloria Gonzalez (Wed & Thurs)
Hannah Christensen (Mon-Fri)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Fri)
Southlake couples counselors
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Gloria Gonzalez (Wed & Thurs)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Fri)
Southlake counselors for 5 to 11 yr old
*
Gloria Gonzalez (Wed & Thurs)
Hannah Christensen (Mon-Fri)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Fri)
Southlake counselors for 12 - 17 yr old
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Hannah Christensen (Mon-Fri)
Gloria Gonzalez (Wed & Thurs)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Fri)
Southlake family counselors
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Gloria Gonzalez (Wed & Thurs)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Fri)
Flower Mound counselors
*
Kali Carter (Mon-Thu)
Lea Ann Crawford (Mon-Thu)
Moran Baxter (Mon-Fri)
Sarah Price (Mon & Thu)
Flower Mound couples counselors
*
Lea Ann Crawford (Mon-Thu)
Sarah Price (Mon & Thu)
Flower Mound family counselors
*
Sarah Price (Mon & Thu)
Flower Mound counselors for 12 to 17 yr olds
*
Kali Carter (Mon-Thu)
Sarah Price (Mon & Thu)
Flower Mound counselors for 5 to 11 yr olds
*
Kali Carter (Mon-Thu)
Sarah Price (Mon & Thu)
Highland Park family counselors
*
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon, Tue, Fri)
Melanie Emerson (Mon, Tue, Fri, Sat)
Sarah Price (Tue-Wed)
Highland Park couples counselors
*
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Wed & Thurs)
Melanie Emerson (Mon, Tue, Fri, Sat)
Sarah Price (Tue-Wed)
Highland Park counselors for 5 to 11 yr olds
*
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Wed & Thurs)
Melanie Emerson (Mon, Tue, Fri, Sat)
Sarah Price (Tue-Wed)
Highland Park counselors for 12 to 17 yr olds
*
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon, Tue, Fri)
Melanie Emerson (Mon, Tue, Fri, Sat)
Sarah Price (Tue-Wed)
Highland Park counselors
*
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon, Tue, Fri)
Melanie Emerson (Mon, Tue, Fri, Sat)
Sarah Price (Tue-Wed)
Telehealth counselors for 8 to 11 yr olds
*
Alix Rudd (Mon-Fri)
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon-Fri)
Hannah Christensen (Mon-Fri)
Kali Carter (Mon-Thu)
Melanie Emerson (Mon, Tue, Fri, Sat)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Mon-Fri)
Telehealth counselors
*
Alix Rudd (Mon-Fri)
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon-Fri)
Hannah Christensen (Mon-Fri)
Kali Carter (Mon-Thu)
Lea Ann Crawford (Mon-Thu)
Melanie Emerson (Mon, Tue, Fri, Sat)
Moran Baxter (Mon-Fri)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Mon-Fri)
Telehealth counselors for 12 to 17 yr olds
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon-Fri)
Hannah Christensen (Mon-Fri)
Kali Carter (Mon-Thu)
Melanie Emerson (Mon, Tue, Fri, Sat)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Mon-Fri)
Telehealth couples counselors
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon-Fri)
Melanie Emerson (Mon, Tue, Fri, Sat)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Mon-Fri)
Telehealth family counselors
*
Alix Rudd (Mon-Fri)
Allie Whistler (Mon-Thu)
Annalisa Blackham (Mon-Fri)
Gloria Gonzalez (Mon-Fri)
Hannah Christensen (Mon-Fri)
Melanie Emerson (Mon, Tue, Fri, Sat)
Rochelle Duke-Rutledge (Wed & Sat)
Sarah Price (Mon-Fri)
What days and times work best for you to meet?
Will you be using insurance?*
Yes
No
full name (as it appears on your policy)
Insurance Company
Aetna
Anthem
Blue Cross Blue Shield
Cigna/Evernorth
Optum
Oscar
Scott and White Health Plan
United Healthcare
UMR
Out-of-Network
Other
Insurance ID Number
age
If you are comfortable doing so, please share something about your reason(s) for seeking therapy.
SubmissionDate
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Month
-
Day
Year
SubmissionDate
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