Contact Me for therapy in San Rafael, CA

Hello! Before you take the time to complete this form, you should know that I only work with clients who want to engage in therapy on a weekly basis (not less frequently). Is this aligned with what you're looking for?*

Yes, that's what I wantNo, I want to meet less frequently

1. First Name*

2. Last Name*

3. What health insurance do you have?*

Please note: The only health insurance plan I am in-network with is Carelon (formerly Partnership Health Plan). All of my Carelon slots are full. You are welcome to email me at mt@maysietifttherapy.com if you want to be added to my Carelon waitlist, but unfortunately I can't predict how soon an opening will be available.

4. Do you have Medicare?*

yesnoI dont know

I am not a Medicare provider. This means Medicare recipents who work with me will not be eligible for any reimbursment from Medicare.

5. E-mail Address*

6. Phone Number*

Area CodePhone Number

7. Were you referred by your employer's EAP program?*

8. Your state of residence (choose one):*

9. Do you prefer video or in-person visits? (if you're ok with either, please check both)*

VideoIn person - San Rafael office

11. How did you find me? (include Google search terms used if you remember - thanks!)*

12. Any comments or basic logistical questions you have? (optional)...