Name *

First Name

Last Name

Phone *

(###)

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What services are you interested in?

Select all that apply.

Psychotherapy

Medication

Mindfulness or Yoga

Not Sure

Other (please write below)

We have some providers who accept insurance (only Blue Cross Blue Shield PPO) and some who are private pay/pay out-of-pocket only. Which best describes your needs around using insurance:

I have BCBS and can only consider seeing a provider who accepts my insurance.

I am open to considering someone who is private pay (you may be eligible to use other benefits).

I am not sure or may need to learn more about what each of these options means.