Ready to start therapy?

Client Name*

Date of Birth (MM/DD/YYYY)*

Are you currently invloved in a criminal/civil/personal injury case? seeking STD/LOA/SSI/divorce or custody paperwork/evaluation to be completed?*

Client Address (number and street name)*

City, State AND zip code*

CLIENT Email (if minor, must be different from parent)*

Phone*

Will you be self-pay or using insurance? please list your insurance (aetna, cigna, BCBS, Optum, etc.)

Do you prefer virtual/in-person/both?

What are best days/times for therapy? Mon-Sat, morning/afternoon/evening?

Do you have a preferred therapist you request to be placed with?

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