Appointment Request Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Therapy Type
*
Child/Teen Individual
Adult Individual
Couples
Family
Availability
Monday
Mornings (9am-11am)
Early Afternoons (12pm-2pm)
Afternoons (3pm-5pm)
Evenings (6pm-8pm
Tuesday
Mornings (9am-11am)
Early Afternoons (12pm-2pm)
Afternoons (3pm-5pm)
Evenings (6pm-8pm
Wednesday
Mornings (9am-11am)
Early Afternoons (12pm-2pm)
Afternoons (3pm-5pm)
Evenings (6pm-8pm
Thursday
Mornings (9am-11am)
Early Afternoons (12pm-2pm)
Afternoons (3pm-5pm)
Evenings (6pm-8pm
Friday
Mornings (9am-11am)
Early Afternoons (12pm-2pm)
Afternoons (3pm-5pm)
Evenings (6pm-8pm
Saturday
Mornings (9am-11am)
Early Afternoons (12pm-2pm)
Sunday
Mornings (10am-11am)
Early Afternoons (12pm-2pm)
Therapist Request
Therapist Request: Please select the therapist(s) with whom you would like an appointment
*
Please Select
Any Therapist
Abigale Walker, MHC-Limited Permit
Agnes Marcano, MHC-Limited Permit
Amanda Dawson, LMHC
Celine Colon- MHC-Limited Permit
Jessica Guzman, LMHC
Jonah Martell, MHC-Limited Permit
Juliette Geilfuss, Advanced MHC Intern
Kamanie Jialal, Advanced MHC Intern
Michelle Kushmakova, LMHC
Liza Dupler, Advanced MHC Intern
Rachel Christensen, MHC-Limited Permit
Taha Ali Alvi, LMHC
If your requested therapist(s) is not available, please tell us your preference
*
I would like an appointment with another therapist
I would like to be added to my selected therapist (s) waitlist
If my requested therapist's waitlist is longer than two weeks, I would like an appointment with another therapist
I am open to meeting with any available therapist
I would prefer a therapist that identifies
*
Female
Male
Don't have a preference
Are We a Good Fit?
Please tell us briefly why you're seeking treatment
*
Are you employed?
*
Yes
No
Other
Are you on psychiatric medication?
*
No
Yes
If Yes, please list below:
Do you have a history of drug or alcohol abuse
*
Yes
No
Other
If other, please describe.
Have you been previously psychiatrically hospitalized?
*
Yes
No
Other
If other, please describe.
Are you presently suicidal?
*
Yes
No
Other
Do you think of hurting yourself?
*
Yes
No
Other
How did you hear about us?
*
Insurance Information
Please select Legal Sex assigned at Birth (This is an insurance requirement)
*
Male
Female
Date of Birth (MM/DD/YYYY)
*
Primary Insurance
*
Please Select
Aetna
Anthem (Blue Cross Blue Shield)
Anthem (Blue Cross Blue Shield Healthplus)
Carelon
Cigna
Fidelis
Healthfirst
MetroPlus
Self Pay
United Healthcare
United Healthcare Oxford
United Healthcare Community Plan
1199
Insurance Member ID Number/Subscriber ID
*
Please upload a front and back picture of your insurance card to expedite the insurance verification process.
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