Intake Appointment Request
Use the form below to request an appointment with Stephanie.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you wanting an In-Person or Virtual appointment?
*
In-Person (Mondays & Wednesdays after 4pm ONLY)
Virtual (All other days and Monday & Wednesday before 4pm)
What time of day works for you to attend appointments? (Select all that apply)
*
Morning
Afternoon
Evening
Weekends
Will you be using insurance or paying out of pocket (self-pay) for services?
*
Insurance
Out of Pocket/ Self-Pay
If using insurance, what insurance do you have?
Please Select
Aetna
Ambetter
Anthem Blue Cross Blue Shield
Anthem EAP
Ascension - Smarthealth
Blue Cross Blue Shield of Massachusetts
Carelon Behavioral Health
Cigna
Cigna EAP
Devoted Healthcare Medicare Advantage
GTEB
Horizon Blue Cross and Blue Shield of New Jersey
Managed Health Services (MHS Indiana)
Humana Medicare Advantage
Independence Blue Cross Pennsylvania
Kaiser Permanente
Oxford - Optum
Oscar - Optum
Quest Behavioral Health
Select Health - Colorado
United Healthcare - Optum
United Healthcare - Optum EAP
United Healthcare - Optum Medicaid
United Healthcare - Medicare Advantage
VA Community Care Network (CCN)
Submit
Individual Therapy - Intake
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