Existing clients, please use the portal to schedule appointments.

We are so HAPPY you made it this far!

If you have not done so yet, please visit our common questions page so you know what to expect at this clinic. Even if you have seen a therapist before, it is helpful to know how this clinic operates. We want you to have the best experience possible as we know for most people, it was already hard getting this far.

Making the decision to get support is often a long journey and you are only a step away. We ask that you fill out this form if you are READY (onboarding takes about 20 minutes) to take on the journey to be accountable to the goals you want to reach. It’s okay if you are not ready, take your time and fill it out once you know that it is the day to DO THINGS DIFFERENT. You may be hesitating because you are not sure if the therapist is a good fit. This is NORMAL. Just schedule several appointments, attend your first one and if it doesn’t feel right, you can cancel the rest of them.

Once you have filled out this appointment request form, someone will email you within 24 hrs (during normal business hours) to get you set up with the best fit therapist. Check your SPAM because often times communication goes there since we are not in your contact list. You can try calling the number listed, however, it is rarely answered as it is a public number and is overwhelmed with solicitation. This will be a personal experience, we just don’t have a full-time receptionist as we are a small locally owned business.

Please indicate below, which insurance plan you carry. If you don’t see your plan below it is because we are not in-network with them, please note that you plan to do self-pay as we do not bill out of network plans.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This appointment request form is for general demographic information to get you set up in the portal for onboarding.

Name *

First

Last

Phone Number *

Email *

Date of Birth (MM/DD/YYYY) *

Date of birth is needed in order to start a portal.

How do you plan to pay for your treatment? *

**We cannot bill straight MA or Medicare. We do not have a contract with them. We can only bill the above mentioned plans and only if they are primary insurance plan. If you see your plan above, this does not guarantee payment. You can to call into your insurance and verify we are in-network with your specific plan. We do not bill secondary insurance. If you choose self-pay, you can request flex spending statements to submit to your insurance if you don’t see your insurance above. ***BY FILLING OUT THIS FORM YOU ARE AWARE YOU ARE SHARING PERSONAL INFO THROUGH A SECURE FORM THAT DOES NOT QUALIFY AS HIPAA COMPLIANT

Please check your SPAM FOLDER for a response (it may go there since we are not in your contact list) Please indicate below if you have a PROVIDER YOU PREFER, have a preference for IN PERSON or TELEHEALTH or any other info that may be helpful (ideally not private clinical information)

By clicking ‘Submit’ you agree that the phone number you provided may be used to contact you.