Client Name*

Email*

Phone*

Therapist Name*

Location*
—Please choose an option—First AvailableHarrisonburgRoanokeTelehealth

Insurance Type*
—Please choose an option—AnthemBlue Cross/Blue ShieldMedCostOptimaPay Out of PocketUse Out-of-Network Benefits


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.