First Name

Last Name

Pronouns

Is client a minor?

Date of birth

Phone *

Email *

Address

City

State *

Postal code

Insurance Carrier Name *

Insurance ID Number *

We offer a cash rate of $65/session. Are you interested in scheduling a session? *

We currently accept Aetna, United Healthcare and Cigna. We expect to accept BCBS in the near future. Our cash rate is $200 for the initial session and $100 for a follow-up. Are you interested in scheduling an appointment for medication at this time? *

New Client Form