Clone of Embrace Free Consultation Request Form

First, let's confirm if we accept your Medical Insurance or what alternative Methods of Payment we offer.* This field is required.We accept CT Husky (Medicaid), Cigna, Evernorth and Aetna insurance plans. All other insurers are considered out-of-network. We also accept out-of-pocket payments.

CT Husky (Medicaid)

Aetna

Cigna / Evernorth

Out-of-pocket Payments

Employee Assistance Program (EAP)

Sliding-scale fees are available only to qualified clients

Other

Thank you for your interest in Embrace's services.

We are not currently in-network with {typeA61}, but we regularly add new insurance networks.

If you would like to join our waiting list, please provide your name and contact information. We will notify you as soon as we join {typeA61}.

If you do not wish to join the waiting list, you may close this form.

Thank you for your interest in Embrace's services.

Please notify me when Embrace joins my insurance network. I would like to join the waiting list.

Yes, I would like to join the waiting list.

Your Name* This field is required.

First Name

Middle Name

Last Name

Phone Number* This field is required.By submitting this form, you agree to receive text message from Embrace about your requested services

Please enter a valid phone number.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

Contact Preference* This field is required.What days/times generally work best for you?

Phone

Text Message

About You or The PatientPlease complete this questions about the patient

Patient Date of Birth

Patient Full Name if different

Patient Phone if different

Patient email if different

Is The Patient a Minor or Under Legal Custody?

If Yes, What Is Your Relationship With The Patient?

Do You Have The Child Legal Custody?

Please Let Us Know How we Can Assist You.* This field is required.

Select Your Available Date and Time.* This field is required.

Appointment Details* This field is required.Please select the services options that best match your needs.

Individual Therapy

Family Therapy

Couples / Marriage Therapy

Teen Therapy (Ages 13–17)

Pre-Teen Therapy (Ages 9–13)

Children’s Therapy (Ages 5–9)

Early Intervention / Play Therapy (Ages 2–5)

Group Therapy

Pre-Marriage Counseling

Retreats

Anger Management

Walk-in Counseling / Same-day support sessions

Walk-and-Talk Therapy / Outdoor Counseling Sessions

Other

Preferred Language of Service* This field is required.Please select the options that best match your needs.

English

Spanish

Other

Session Format PreferencePlease select the options that best match your needs.

In-person

Telehealth (virtual sessions)

Home Visits

Other

Availability* This field is required.What days/times generally work best for you?

Mornings

Noon

Afternoons

Evenings

Night

Weekends

Accessibility & AccommodationsDo you require any special accommodations? (If, Yes. Please describe below)

YESNO

Additional notes:

Terms and Conditions* This field is required.By submitting this form, you agree to receive communications from Embrace about your requested services and accept our terms and privacy policy.

Please verify that you are human* This field is required.

Clone of Embrace Free Consultation Request Form