Consultation Request
Complete this form to inform us of your needs. Once we review the form, we will reach out to learn more about you and confirm your next steps.
Sign in to Google to save your progress. Learn more
Email *
Disclaimer
Any information entered into this form is confidential and will not be shared outside of it's intended use. If you are in a crisis, do not complete this form. Instead call 988 to receive immediate help. No liability is assumed at your completion of this form. Again, if you are in a mental health crisis text or dial 988, if you are experiencing a medical emergency dial 911.
What is your name? *
If you are inquiring for a minor, what is their age? Please note services start with ages 11 and up.
What is your company/business name?
Preferred pronouns *
Email address *
Phone number *
Preferred method of contact *
Service type (all therapy sessions are currently virtual only) *
Insurance Information
We currently accept the following insurances:
  • UnitedHealthcare
  • Oxford Health Plans
  • Cigna
  • Aetna
  • UMR
  • Oscar
  • UHC Student Resources
  • AllSavers UHC
  • Harvard Pilgrim
  • Meritain
  • Nippon
  • United Healthcare Shared Services
  • Allied Benefit Systems - Aetna
  • Surest (Formerly Bind)
  • Health Plans Inc.
  • UnitedHealthcare Global
  • Christian Brothers Services - Aetna
  • Trustmark Health Benefits - Aetna
  • Trustmark Health Benefits - Cigna
  • Trustmark Small Business Benefits - Aetna
  • Health Scope - Aetna
  • BCBS/Anthem
Will you be using insurance? *
Select your insurance provider from the drop down list. If you are not using insurance please select that option.
Is there anything you want to share prior to hearing from Angel?
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms