Name *

First Name

Last Name

What can we help with today? *

Appointment for Therapy

Appointment for Premarital Counseling

Questions about supervision

General questions

If you're interested in Individual therapy please check any concerns that apply to you *

Depressed mood

Excessive worry

Panic

Self Harm

Suicidal Ideation

Recent/traumatic loss- Grief

Interpersonal conflicts

Disruptions to sleeping and eating habits

Job dissatisfaction or academic difficulties

Poor body image

Low self esteem

Excessive exercise

Forced food restriction

Forced purging

Binge eating

Shame around food/eating

Difficulty adjusting to a life transition

I'm not reaching out for individual therapy

How would you like to meet? *

Telehealth

In Person

I am 16 years old or older *

Yes

No

If you'll be using your insurance, who is your insurance provider? Please be advised, we will no longer be accepting new clients with the following insurance: Independence Blue Cross/Blue Sheild, Independence Administrators, Amerihealth, or Amerihealth Administrators. *

Aetna

United Healthcare/Optum/UMR

Horizon or other Blue Cross/Blue Shield

I plan to pay out of pocket or use my out of network benefits