Tell Us More About Yourself

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We accept self-pay and many insurance carriers. If you would like to see if you can use insurance, please provide information here and we will confirm with you.

Anxiety LP Form 2

Insurance Name, ID number, Group Number, Any plan symbols (like PPO, EPO...) *

Mental Health on back of your insurance card, not all plans cover therapy. Call your plan for costs and coverage. We can not bill Medicare or secondary insurance.

Date of Birth *

Potential New Client's Birth Date (13 years of age on up to 100+)

Concern that has you seeking Therapy *

Briefly tell us what you need so we can best match you to one of our Therapists.

How did you hear about us *

We'd love to know how you found us! Online? Friend? Dr referral? etc...

Other Comments

Anything additional you would like to share with us?

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