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*
Format: (000) 000-0000.
Gender Identity*
Sex (as listed on insurance policy)*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
What is the primary reason you're seeking therapy at this time?*
Have you had an in-patient hospitalization in the past month for mental health reasons?*

YesNo
Are you primarily seeking support for substance use (alcohol or drugs)?*

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

Individual TherapyCouples TherapyFamily TherapyPsychiatry/Medication ManagementBoth Therapy & Psychiatry
Is this treatment court ordered?*

YesNo
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.Format: (000) 000-0000.
Date of Birth of Partner/Spouse/Additional Member*

MonthDayYear
Date
Sex (as listed on insurance policy)*

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

Chelsy Taylor, LMSWJennifer Nicastro, LACSteven Rodriguez, LACVallerie Hancock, LPC
Provider bios can be found on this page.
Which therapist(s) would you like to work with in Colorado?*

Amanda Baker, LSWAmber Fratini, LPCCAshly Andersen, LPCCBreanna Cubilla, LSWCheryl Turonis, LSWChristopher Emerson, LPCCConsuela Galvan, LSWCrystal Soto, SWCHeidi Emerson, LPCCJennifer Rodriguez, SWCJennifer Vargas, LPCCKasandra Hill, LPCCKatherine Robles, LSWKeisha Machado-Cintron, LPCC (Spanish & English)Marcela Carbajal, LPCC (Spanish & English)Oscar Lozano, SWC (Spanish & English)Oscar Machado-Galaviz, SWC (Spanish & English)Sarah Miller, LPCCSheherazade King, LPCCTeresa Keller, LPC (Spanish & English)Yasmine Lamour, LPC
Provider bios can be found on this page.
Which therapist(s) would you like to work with in Massachusetts?*

Amanda Jankoli, LICSWAshley Lussier, LCSWHaven Huck, LCSWKathryn Boyle, MHCSusana Martinez-Arevalo, LCSW (Spanish & English)
Provider bios can be found on this page.
Which therapist(s) would you like to work with in Virginia?*

Aerielle Washington, SiSWCarsyn Pauley, RICEleanor Martin, SiSWJaida Fehrman, RICJason Moore, RICJennifer Burkett, RICMarissa Smitton, SiSWMonica Karafotis, RICRebeckah Atkinson, RICShontelle Ramsay, SiSWStephanie Harrison, SiSWTanitha Nicholas, RICZachary Cleland, RIC
Which psychiatrist(s) would you like to work with in Virginia?*

Amaninder Grewal, PMHNP-BC
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 or psychiatrist.
Do you consent to receiving SMS reminders regarding your appointment?*

YesNo
By checking the box below, I agree to receive account-related and informational text messages from Third Space Therapy, such as alerts, reminders or notifications. Message frequency varies. Message and data rates may apply. Reply STOP to opt out. View our Privacy Policy and Terms
By checking the box below, I agree to receive marketing text messages from Third Space Therapy at the phone number provided. Message frequency varies. Message and data rates may apply. Reply STOP to unsubscribe or HELP for help. View our Privacy Policy and Terms
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*
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Request an Appointment

About the individual receiving services

Session Preferences

Insurance Information

Consents