First Steps With Emerald Therapy Center!

We promise this will be quick. Once you've filled out our form, we'll contact you to schedule your first appointment with us. These are the first steps to better days ahead! If you are in a crisis situation, please call 988 or visit your local emergency room. You are not alone!
What would you say are your biggest challenges today?*

Attention Span IssuesDepressionGriefAddictionAnger ManagementParenting IssuesGender/Sexuality IssuesEating DisordersBehavioral IssuesRelationship IssuesAnxietyFamily IssuesUnsureOther
What services are you most interested in?*

Couples CounselingAddiction TreatmentAnger Management ClassesParenting ClassesFaith-Based CounselingAlternative to In-Patient TherapyIndividual TherapyTelehealthFamily CounselingMRT ParentingMRT AngerMRT Staying QuitTeen Group ProgramPsychiatryMedication ManagementTMS (Transcranial Magnetic Stimulation)IV Ketamine (not covered by insurance)Facial Therapy (not covered by insurance)Vitamin Therapy (not covered by insurance)UnsureOther
What type of experience are you open to?

I prefer to see someone in personI'm open to Telehealth optionsI'm open to either in person or telehealth
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Gender*
Guardian's Name (if applicable)

First NameLast Name
Phone Number*

Area CodePhone Number -- By providing a mobile number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Social Security Number
Who is your insurance carrier?
This is required to verify benefits for certain insurance carriers. Please skip if you plan to pay as a self-pay client or if you prefer to give this to us over the phone when we reach out to schedule your first appointment.
Policy Holder's Name:  First Name   Last Name
Policy Number:
Group Number:
Group Name:
SSN:   000-00-000
Insurance Card

Browse Files
Please upload a photo of the front and back of your insurance card. Cancelof
Our Promise: Mental Health Services Cannot Wait. One of our representatives will reach out within 24 business hours to schedule an initial appointment. If you are in a crisis situation, please call 988 or visit your local emergency room.*

I understand
Existing Clients

I understand
Address

Street Address

Street Address Line 2

CityState

Zip Code
What can we help you with?

AnxietyADHDDepressionGriefCouples CounselingAddiction TreatmentAnger ManagementParenting ClassesMRT- Re-entryGender IssuesEating DisordersFaith-Based CounselingAutism Spectrum DisorderBehavioral IssuesOther
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