First Name
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Last Name
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Phone
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Email
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Where did you hear about us?
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Psychology Today
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Preferred Location
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Woodmen Rd
Fountain Blvd
North Academy Blvd
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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
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How can we support you? What have you been experiencing and for how long?
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If you have had therapy in the past, what was your experience like?
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Have you been hospitalized for psychiatric concerns? If so, when and for how long?
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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.
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Are you currently taking medication prescribed to treat mental health? If so, kindly list medications.
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Therapy Preference
In Person
Teletherapy
First Available
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