Patient Name*

Email*

Phone*

Preferred therapist

Please choose your primary reasons for seeking counseling. We understand you may have more than one concern. You may tell us more about what kind of help you are looking for below.
stress/anxietyangerdepression/moodeating disordertrauma/PTSDLGBT supportrelationship - individual counselingrelationship - couples counselingfamily concernssubstance usegrieflife changesteen concernschild therapyother

Type of insurance
AnthemAetnaOptimaTricareOut of networkPrivate pay

Insurance member ID number* (subscribers SSN for Tricare)

Patient date of birth*

Please let us know what kind of help you are looking for. If you have certain days or times in mind, please let us know here.

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Would you like to be added to our wait list if an immediate appointment is not available?
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