Initial Request

  • Initial Request

  • This adaptive form takes 2–3 minutes to complete and provides immediate feedback on whether we accept your insurance and if we specialize in treating your concerns.
    We try to contact everyone within 24 hours (excluding Fridays). If you have any issues or prefer to speak with someone directly, feel free to call or text us at 319-853-8762.

  • Format: (000) 000-0000.
  • What is the best way to contact you?*
  • Which location(s) are you open to receiving services at? (Check all that apply)*
  • How did you hear about us?*

  • Do you have insurance?

  • What type of insurance do you have?*
  • We are only credentialed with certain insurance companies. We do not take United Behavioral Health, VA insurance, Medicaid, EAP insurances, or any insurance not listed in the previous question. Are you interested in paying out of pocket (the fee is $130/session)?*

  • Understanding Insurance

  • Are you aware of your coverage and know your copays and/or deductibles?*

  • Presenting Problems

  • Check the boxes of problems you are experiencing. If you are not experiencing any of these issues, please check the last box.*
  • Check all the problems that apply*

  • Services We Do Not Provide

  • There are some services we do not provide, including writing letters for support animals, testifying in lawsuits, diagnosing for lawsuits, or conducting therapy for the sole purpose of supporting a disability claim. Are you seeking help for any of the above issues?*

  • Previous Therapy

  • Have you ever had psychotherapy (Talk Therapy)*

  • Treatment Options

  • What kind of therapy are you looking for? (check all that apply)*

  • Couples Therapy

  • Has your partner agreed to come to couples therapy?*
  • What describes your relationship (read all the options, check all that apply)*

  • Therapy for Your Child

  • We apologize, as we do not have any providers who treat children 3 years or younger. We suggest you contact the University of Iowa Psychiatry Department, as they may have providers who can help.

  • What is your relationship status?*

  • Co-Parent Agreement

  • Does your co-parent consent to your child receiving therapy?*

  • Can We Contact Your Co-Parent?

  • We are required to confirm both parents are in agreement with therapy, unless your partner has medical decision making rights (we will need to see a court decree). Are you OK with us contacting your partner and/or co-parent to confirm they are in agreement with therapy?*

  • Under Iowa law, we are required to obtain consent from both parents before providing therapy to a minor, unless one parent does not have legal rights regarding medical decision-making. If you’re unsure about your situation or have questions, please feel free to call us at 319-853-8762 so we can discuss the next steps.

  • Child Therapy Problems

  • Adult Individual Therapy

  • Have you ever been in a hospital or residential setting for mental treatment?*

  • Helping Someone Else Find a Therapist

  • Does the person you are helping know you are contacting therapists on their behalf?*
  • What is your relationship to the person you are trying to help?*

  • Therapy Request by Teen

  • Is it OK if we contact your parent or legal guardian?*

  • Submit Form

    Click the submit button below. We will have one of our therapists look over your responses and our office staff will get back to you about your appointment. Thank you for completing this form.
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