Request an Intake with a Therapist

Please be aware that many of our services are a self-pay services. We are considered an out of network provider, and you will be responsible for the full fee at the time of service; however, we can provide you with a Superbill for you to submit to your insurance.

If you have out-of-network benefits, you may be reimbursed directly by the insurance company for a percentage of the fee, based on what your plan allows, if applicable. In order to place you with the right clinical team member, please fill out this form and a staff member will reach out to you to schedule your desired service after your request is staffed with our clinical care team.

Patient Name

First Name

Last Name

Parent or Guardian Name (if applicable)

First Name

Last Name

Client's DOB

YYYY

Client or Parent Email

Phone Number for Follow-up

What Brings You to Therapy?

Please tell us what you're needing from therapy, the severity of your symptoms and goals.

Desired Service

Individual Therapy

Couples Therapy

Family Therapy

Dietician/ Nutrition

Yoga

Type of Therapy/ Services Received Previously

Availability?

Anything You Would Like Your Provider to Know

Location of Services

In-Person, at our Center

Telehealth