* PLEASE LEAVE YOUR EMAIL ADDRESS AND PHONE NUMBER OR WE WILL NOT BE ABLE TO CONTACT YOU.
* PLEASE DO NOT LEAVE THE CONTACT INFORMATION SECTION BLANK. WE CANNOT CONTACT ANYONE WITHOUT AN EMAIL ADDRESS OR PHONE NUMBER.
* PLEASE INPUT YOUR INSURANCE MEMBER ID ON THE FORM OR YOUR FORM WILL BE INCOMPLETE. After insurance verification, we will contact you if your plan includes a deductible to meet or co-payment for sessions.
* Please note we will review your request, however, we may not be able to accommodate every request. Request are subject to approval for ALL THERAPIST.
* After you complete this form, you will be sent consents forms electronically from our platform THERAPLATFORM that MUST be signed before you may proceed with services.
* After completion of consents, a therapist will reach out to you to schedule an intake assessment. When intake is complete, your assigned therapist will reach out at their earliest convenience to schedule an appointment to begin psychotherapy.
If you have any questions, please feel free to reach out to us at 912-737-2176.*