Client Name*

Email*

Phone*

Therapist Name*

Insurance Type*
—Please choose an option—AnthemBlue Cross/Blue ShieldOptimaUse Out-of-Network BenefitsPay Out of Pocket
Please choose your Insurance type. The Insurance listed are those we are In network with. Any insurance that is not listed, we are not in network with. If you would like to be seen, you may use your out of network benefits or pay our out of pocket rate.

Client Date of Birth*

Additional information*

Please let us know your reasons for seeking counseling. If you have a specific therapist in mind, certain times or days you need, feel free to let us know here.