About Us
Services
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Our Team
FAQ
Media
Blog
Book A Session
Contact Us
About Us
Services
Rates + Insurance
Our Team
FAQ
Media
Blog
Book A Session
Contact Us
Getting Started
Please complete the form below. Our intake coordinator will get back to you within 2 business days.
Name
*
First Name
Last Name
Pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Email
*
Phone
*
(###)
###
####
Preferred Contact Method
*
Email
Phone
No Preference
How did you hear about us?
Referral from Friend/Professional
Online Search
Therapist Database
Social Media
Other
Desired Service
Individual Therapy
Couples Therapy
Group Therapy
Sport + Health Psychology Consulting
Corporate Wellness
Reiki
Insurance Carrier
*
Aetna
Allied Benefit System
BCBS PPO
Blue Choice PPO
Cigna
United/Optum
Self-Pay
Member ID
*
Please write N/A if self-pay
Group Number
*
Please write N/A if self-pay
Customer Service or Provider Phone Number
*
This phone number can often be found on the back of your insurance card. Including this number will expedite verification of benefits. Please write N/A if unsure.
Date of Birth
*
Date of Birth is needed to verify insurance benefits.
MM
DD
YYYY
Zip code
Please indicate the zip code that is attached to your health insurance account.
Preferred Appointment Day and Time
*
Check all that apply.
Weekdays from 8am-11am
Weekdays from 11am-2pm
Weekdays from 2pm-5pm
Weekdays from 5pm-9pm
Saturdays 8am-1pm
Sundays 2pm-7pm
Preferred Location
*
Video
Office
No Preference
Reasons for Appointment
Please check all that apply. If you do not see your reason for attending therapy listed, or want to expand on any of the items listed, please do so below in the message box.
Anger Management
Anxiety
Body Image
Chronic Pain + Illness
Cultural Concerns
Depression
Eating Disorders
EMDR
Grief
Health Coaching
Identity Development
Life Transitions
OCD
Relationship Issues
Self-Esteem
Sport + Performance Psychology
Stress Management
Substance Use + Addiction
Suicide + Self-Harm
Trauma + PTSD
Women's Issues
Other
Message
Please include any information about why you are seeking our services at this time. This information will help us to determine which of our clinicians might be the best fit for you. If you have more specific preferences for appointment days and times than what is listed above, please indicate that here.
Thank you!
