Please note: we will only respond to this inquiry by phone if specifically requested in the last field of this form - otherwise, please look out for an email from us. Please also note that by providing your phone number, you are consenting to an occasional text message notification pertaining to scheduling or services. You may revoke this consent at any time.
Select "Other (write-in)" if your city and state are not listed.
This field is required. Knowing what kind of insurance you have will allow us to link you with a therapist in network with that insurance.
Name of your EAP (ie- ComPsych, Cigna, Anthem, etc.,)
If you do not know the EAP name, please write your employer's name or the name of the service you believe is paying for sessions.
Please enter the details of your request. A member of our support staff will respond as soon as possible.