Schedule Your Initial Consultation Today. We invite you to explore how our approach can support you in embracing life’s changes and finding your way through its many currents. Contact us to learn more about how we can work together to navigate the flow of your life. Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Client's Date of Birth * Example: January 7, 2019 Sex Assigned at Birth * Mark only one. Male Female What is your gender identity? Which pronouns do you use? If under 18, Parent or Legal Guardian's name and relationship. Example: John Doe, Father Availability Mark only one Daytime Evening How will you pay for services? * Mark only one. Insurance Self-Pay Who is your insurance provider? Select provider below Aetna Blue Cross Blue Shield Cigna United/UMR/Optum Medcost Presenting Concern: Tell us why you are seeking counseling/therapy. * Who were you referred by? Friend/Family Doctor Search Engine Insurance Website Thank you!
