New Client Form
First Name
Last Name
Pronouns
Is client a minor?
Date of birth
Phone
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Email
*
Address
City
State
*
Postal code
Insurance Carrier Name
*
Insurance Carrier Name
Insurance ID Number
*
We offer a cash rate of $65/session. Are you interested in scheduling a session?
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Yes or No
Presenting Issue
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Anxiety
Depression
Relationship Issues
LGBTQ+ Issues
Maternal Mental Health
Bipolar Disorder
Life Transition
Bullying
BPD
Perfectionism
Loss of a Pet
Loss of a Loved One
Work Related Stressors
Sexual Assault/Abuse
Trauma
Other
Are you interested in therapy, medication or both?
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We currently accept Aetna, United Healthcare and Cigna. We expect to accept BCBS in the near future. Our cash rate is $200 for the initial session and $100 for a follow-up. Are you interested in scheduling an appointment for medication at this time?
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Yes or No
Availability
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Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Weekends
