First Name *

Last Name *

Phone *

Email *

Where did you hear about us?

Preferred Location *

What type of insurance do you have? We currently work with Tricare, Aetna, and Private Pay policies. Please include your insurance benefits number. We are not credentialed with Medicaid/Medicare and are unable to see clients with this type of insurance coverage *

How can we support you? What have you been experiencing and for how long? *

If you have had therapy in the past, what was your experience like? *

Have you been hospitalized for psychiatric concerns? If so, when and for how long? *

Have you previously been diagnosed with a disorder or particular mental health challenge? If so, kindly provide a date range and name or details about the disorder. *

Are you currently taking medication prescribed to treat mental health? If so, kindly list medications. *

Therapy Preference