Appointment Request Form

Request an Appointment
Phone: (833) 244-4878

Email: appointments@talkthirdspace.com

We're currently accepting patients and have same-week appointments available for eligible plans. Please complete this form so we can schedule your first appointment with us.
Who are you booking this appointment for?*

For myselfFor someone else
How old is the individual receiving services? *
Which state are you located in?*

ArizonaColoradoMassachusettsVirginiaOther
About the individual receiving services

Please provide the following information for the individual receiving services. Ensure all details match exactly as they appear on the patient’s insurance card.
First Name*
Last Name*
Preferred Name (optional)
Date of Birth*

MonthDayYear
Email Address*
Phone Number*
Gender Identity*
Sex (as listed on insurance policy)*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Session Preferences
What type of service are you looking for?*

Individual TherapyCouples TherapyFamily Therapy
For Family Therapy & Couples Therapy, please provide the following information for the other individual(s) joining the session:
First Name of Partner/Spouse/Additional Member*
Last Name of Partner/Spouse/Additional Member*
Email of Partner/Spouse/Additional Member*
example@example.com
Phone Number of Partner/Spouse/Additional Member*
Please enter a valid phone number.
Date of Birth of Partner/Spouse/Additional Member*

MonthDayYear
Date
Sex (as listed on insurance policy)*

FemaleMale
Which provider(s) would you like to work with in Arizona?*

Jodie Gonzalez, LPC
Provider bios can be found on this page.
Which provider(s) would you like to work with in Colorado?*

Amanda Baker, LSWAmber Fratini, LPCCAshly Andersen, LPCCCharmagne Grove, LPCCCrystal Soto, SWCHanna Lee, SWCHeidi Emerson, LPCCKeisha Machado-Cintron, LPCC (Spanish & English)Kelsie Books, LPCCOscar Lozano, SWC (Spanish & English)Sarah Miller, LPCCSheherazade King, LPCCYasmine Lamour, LPCC
Provider bios can be found on this page.
Which provider(s) would you like to work with in Massachusetts?*

Amanda Jankoli, LCSWAshley Lussier, LCSWHaven Huck, LCSWMaureen Lane, LMHCSusana Martinez-Arevalo, LCSW (Spanish & English)
Provider bios can be found on this page.
Which provider(s) would you like to work with in Virginia?*

Aerielle Washington, SiSWBryan Lewis, RICCarsyn Pauley, RICTanitha Nicholas, RICVictoria McMahon, SiSW
Provider bios can be found on this page.
If your preferred providers are not accepting patients, can we match you with another provider?*

YesNo

Insurance Information

Please provide the following information for the individual receiving services. Ensure all details match exactly as they appear on the patient’s insurance card.
Insurance Type*

Medicaid (AHCCCS)MedicareCommercial/PrivateTRICARESelf-Pay
Medicaid Insurance Plan*
Commercial Insurance Plan*
Medicare Insurance Plan*
TRICARE Insurance Plan*
Insurance Type*

Medicaid (Health First Colorado)MedicareCommercial/PrivateTRICARESelf-Pay
Medicaid Insurance Plan*
Commercial Insurance Plan*
Medicare Insurance Plan*
TRICARE Insurance Plan*
Insurance Type*

Medicaid (MassHealth)MedicareCommercial/PrivateTRICARESelf-Pay
Medicaid Insurance Plan*
Commercial Insurance Plan*
Medicare Insurance Plan*
TRICARE Insurance Plan*
Insurance Type*

Medicaid (Cardinal Care)MedicareCommercial/PrivateTRICARESelf-Pay
Medicaid Insurance Plan*
Commercial Insurance Plan*
Medicare Insurance Plan*
TRICARE Insurance Plan*
Insurance Type*

MedicaidMedicareCommercial/PrivateTRICARESelf-Pay
Insurance Plan*
If you selected Self-Pay, please note that Medicaid (AHCCCS/Health First Colorado/MassHealth/Cardinal Care Virginia) patients are not legally allowed to be charged a self-pay fee.*

Yes, I confirm that I am not on a Medicaid plan in my state, and I'm eligible for a cash-pay session at a rate of $90
Insurance ID Number*
Please upload a copy of the front and back of your insurance card*

Cancelof
I’m not able to upload photos of my insurance card at the moment, but I understand this may be required before scheduling.
Is the individual receiving services the primary subscriber of this plan?*

YesNo
Consents

By submitting the form, you consent to Third Space using the times you provided to schedule your appointment with a therapist.
Do you consent to receiving SMS reminders regarding your appointment?*

YesNo
How did you hear about Third Space?*
Please share how you heard about Third Space*
If you were referred to Third Space, please enter the name of the referring provider and their practice name*
source
ad type
Should be Empty:

	Monday	Tuesday	Wednesday	Thursday	Friday
8AM – 9AM
9AM – 10AM
10AM – 11AM
11AM – 12PM
12PM – 1PM
1PM – 2PM
2PM – 3PM
3PM – 4PM
4PM – 5PM
5PM – 6PM
6PM – 7PM
7PM – 8PM
8PM – 9PM

Request an Appointment

About the individual receiving services

Session Preferences

Insurance Information

Consents