Consultation Request

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Please complete this secure form and after submission you will be redirected to book your free consultation call through our internal system.

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Last Name *

First Name *

Email Address *

Phone Number *

Age *

Where are you located? *

New York

New Jersey

Connecticut

Massachusetts

Texas

North Carolina

Florida

Wymagane

Which therapist are you looking to have a consultation with? If you are not sure who you would like to book with, please book your call with Mary Tate to help match you with the best fit. *

Mary Tate, LCSW

Muriel Radocchio, LCSW

Radyale Blaylock, LCSW

Elizabeth Bittiker, LMFT

Please share any details that may be helpful for the therapist to know prior to your call. (what you hope to work on, current symptoms, questions you may have)

Payment Preference *

Out of Pocket

Out of Network (we will help walk you through the claim process!)

In-Network with Aetna with Elizabeth (current waitlist for in-network)

In-Network with Cigna with Muriel (current waitlist for in-network)

In Network with UHC/Optum/UMR/Oscar/Oxford with Rayale (limited availability)

Inne:

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What is your primary health insurance? *

This is helpful for us to know prior to your call to discuss anything related to reimbursement!

Aetna

Oscar

Optum

UMR

Oxford

Blue Cross Blue Shield

Cigna

United Healthcare

Inne:

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Will you or a 3rd party be responsible for financial responsibility? This gives us a heads up on how to review any financial questions that you may have during your call! *

I will be responsible for all financial responsiblity.

A 3rd party will be responsible for financial responsibility. (Parent, Spouse, Family Member, Friend, Employer)

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Tate Psychotherapy LCSW PLLC is unable to provide care to beneficiaries of Medicare, even if you are paying for services privately.

I confirm that I do not have Medicare

How did you find us? *

Do you have a preference of how we communicate with you prior to your consultation? *

Text

Phone Call

No preference!

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