Client Information Request
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Enter your Cigna Member ID number. If you are using Private Pay, please enter “Private Pay.” VACCN clients should contact their local VA Medical Center and request Tamia Barnes Tomasek Counseling as their practice of choice.
Please indicate your preference for a male or female therapist and whether you prefer in-person sessions, telehealth, or have no preference.
Submit
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