Name *

First Name

Last Name

Phone *

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Do you understand that you will be responsible for payment of sessions and that in certain cases, your insurance may cover a portion of these services?

Yes

If you are planning on using your insurance, please select which plan you have and if not, please select the option indicating you are not planning on using insurance. *

BCBS PPO

Aetna

United

Other

I'm not planning on using my insurance

Please select the type of sessions you are seeking *

In-person sessions

Virtual sessions

Hybrid (virtual and in-person sessions)