SECURE CONTACT FORM

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SECURE CONTACT FORM

Please use this form to reach out to us. Do not use this form for emergencies. We will respond within 24-hours.

Name (does not need to be your legal name) *

Email *

Pronouns *

What is your (or the client's) date of birth? *

Phone number

State Located *

Other:

Required

How can we help? *

Individual therapy for adult

Individual therapy for a child or teen

Relationship/couples therapy

Care coordination

Gender affirming surgery letter

Other:

Required

In 2-3 sentences, what are you looking for help with? *

What are you looking for in a therapist? Do you have a particular therapist you are interested in seeing? *

We are only in-network with Aetna, but can help you access out-of-network benefits if you have them with another insurance. What is your insurance situation? *

I have Aetna.

I would like to use my out-of-network benefits and I am willing to pay out-of-pocket for a good fit

I will be self-pay, I do not want to use my insurance.

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