Initial Contact
Rebecca Pearce, PsyD
Name
*
First Name
Last Name
Phone Number
*
If you are calling on behalf of a child or someone else, please let me know who you are calling for...
First Name
Last Name
...and what is your relationship to that person:
Please leave your email ONLY if do not have a cell phone for me to reach you.
example@example.com
How did you hear about me?
*
Under new federal laws (effective 1/1/22) I am required to ask if you have any kind of health insurance coverage, and whether or not you intend to submit a claim to your insurance.
*
I will self-pay because I do not have insurance.
I have insurance, but intend to self-pay and leave insurance out of it.
I have insurance but intend to self-pay and submit the claims to insurance myself.
I have insurance, and will ask you to submit claims on my behalf.
I'm not sure - can we talk about this?
Name of insurance carrier
*
If you you do not have insurance, or you do not intend to bring your insurance company into your psychotherapy, simply put "N/A" here
When are you available for sessions?
(please let me know which days of the week , and time of day ~ e.g. Monday: morning & midday, Tuesday: afternoon, Thursday: evening, etc. )
Are you mostly interested in
in-person sessions
virtual sessions
either works for me
If you wish, please say a little bit about what you'd like to address here:
Please verify that you are human
*
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