Appointment Request Form

Appointment Request Form

Let us know how we can help you!
Unfiltered Therapy is dedicated to providing you with the best therapy experience. We are looking forward to teaching you the skills to produce long term results. Before we connect, we want to take the time to understand your therapy goals and preferences. Please help us out by answering the below questions.
Full Name*

First NameLast Name
Are you seeking treatment for a child or adolescent? If yes, please provide the name and age of minor seeking treatment. No Yes*
Name of minor Age of minor
Client's Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Therapy preference*

In-PersonTelehealth
What's your availability for appointments?*

MorningAfternoonEveningFlexibleSpecific days?
What would you like to be treated for?*

AnxietyDepressionOCDPanic AttacksTraumaPostpartumFertilityPerinatal Mood DisordersBirth TraumaGrief and LossSpecific PhobiaAgoraphobiaOther
What type of therapy are you interested in?*

Individual TherapyGroup TherapyPrenatal & Postpartum SupportEMDRParental ConsultationsFree Virtual Postpartum Group*Unsure at this time
Is there a specific clinician you would like to see?*
Would you be comfortable seeing an intern or psychological associate that is under the supervision of a licensed clinician?*

YesNo
Are there specific questions you would like to ask?
How did you hear about us?*
Fees & Insurance:

Individual therapy sessions with a licensed psychologist are $300 per session.

Individual therapy sessions with an unlicensed therapist are $150 per session.

Group therapy sessions are $60 per session with commitment to attend entire series.

*Free Virtual Postpartum Group is offered at no cost.

We do not accept insurance; however, we can provide you with a superbill to submit to your insurance for reimbursement.
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