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Waitlist Request Form
Please complete the following form to be added to Resolve Therapy's waitlist.
* Indicates required question
First and Last Name:
*
Your answer
Email Address:
*
Your answer
Phone Number:
*
Your answer
What type of therapy are you seeking?
*
Individual therapy for myself
Individual therapy for a minor
Couples therapy
Family therapy
Other:
Required
Are you currently located in California?
*
Yes
No
Are you able and willing to do telehealth (virtual) sessions?
*
Yes
No
Please list your availability for sessions:
*
Monday afternoons (1-4 PM)
Monday evenings (5-8 PM)
Tuesday afternoons (1-4 PM)
Tuesday evenings (5-8 PM)
Wednesday afternoons (1-4 PM)
Required
What (if any) insurance plan would you like to utilize?
*
Cigna/Evernorth
Optum/United
TriCare
Other:
Required
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